Question
I have a student that presents with a multitude of problems, one of which is verbal dyspraxia. His speech is remarkable for dysfluency (for example, d-d-d-d dog and fffffffffire). Is this another symptom of dyspraxia or is this a separate concern? And
Answer
The simple answer to your first question is that stuttering is not a symptom of dyspraxia; however, there is some research that makes your question an interesting one and makes my response to your question somewhat equivocal. Although there could be some connection between the two disorders in your child, it could always be possible that the two disorders could just be co-existing. As Kent (2000) reminds us, children who stutter are more likely than non-stuttering children to exhibit other speech and language problems.
In 1974, Yoss and Darley suggested that stuttering as well as articulation difficulties might be expressions of developmental apraxia. Whether or not Yoss' and Darley's suggestion is true, both stuttering and apraxia "have been defined or studied in terms of speech motor control dysfunction...[even though] the fluency disorders...are not always classified in this way" (Kent, 2000, p. 391) and there is plenty of controversy regarding this issue.
Neuroimaging techniques are beginning to give researchers new insights into sites of abnormality that were not previously available. In developmental apraxia, Kent (2000) cites studies that found abnormalities in cortical and subcortical motor related areas of the frontal lobe. The studies also identified the basal nuclei, particularly the caudate nucleus, as being abnormally small.
Kent's review of the some of the neuroimaging research in individuals who stutter suggest that "stuttering can result from a variety of neurological disturbances and is not necessarily related to damage to any one structure or neural pathway". One of the structures that has been implicated in stuttering is the basal nuclei.
Most of us have witnessed the groping behaviors during the motor programming efforts of individuals with apraxia. We have also seen groping posturing of the articulators in children who stutter as they try to "program" their speech. Blomgren and Nagarajan (2002) have observed, through neuroimaging, a reversal of cortical activation sequences during motor programming of individuals who stutter in that they initiate the motor program before preparing the articulatory code. Most of us are also aware of the effortful nature of apraxic speech and of stuttering behaviors. It is possible that the tense behaviors of apraxic speech are classically conditioned or paired with normal dysfluent behaviors, which then develop into a stuttering disorder in the same fashion as classical conditioning may occur in individuals who stutter without apraxia. It is also possible that a version of Bloodstein's Communication Failure theory of stuttering (1995) may be operating in the child with apraxia, in that the child with apraxia experiences communication failure and talking difficulty. This results in tension when talking. Since stuttering is a tension behavior, stuttering may develop as a result.
Regardless of whether the stuttering is related to the dysapraxia or whether it is a separate concern, I would suggest that you primarily address the apraxia. As you address it, you might consider attempting strategies designed to take the effort out of speaking and phonating. In addition, it is well known that both apraxia and stuttering respond well to rhythms and melodic types of strategies. These strategies might help you to manage the fluency difficulties as well. One other note: researchers (Nippold, 2002) have found no evidence that working on articulation (apraxia) is related to an increase in dysfluency. In fact, it is perfectly all right to work on fluency and articulation concurrently (Ratner, 1995). Some sources that might assist you in treating your child include the following:
Pannbacker, M. (1988). Management strategies for developmental apraxia of speech: A review of literature. Journal of Communication Disorders, 21, 363-371.
Caruso, A. J. & Strand E. A. (Eds.)(1999). Clinical management of motor speech disorders in children. New York: Thieme.
Helfrich-Miller, K. (1984). Melodic intonation therapy with developmentally apraxic children. Seminars in Speech and Language, 5, 119-126.
Sources
Bloodstein, O. (1995). A handbook on stuttering, 5th ed. San Diego: Singular Publishing Group., Inc.
Blomgren M., & Nagarajan, S. (2002, August) Functional neuroimaging of speech production in people who stutter. Perspectives on Fluency and Fluency Disorders, 12, (2) pp. 3-6. American Speech-Language-Hearing Association Division 4.
Kent, R. D. (2000). Research on speech motor control and its disorders: A review and prospective. Journal of Communication Disorders, 33, 391-428.
Nippold, M. (2002). Stuttering and phonology: Is there an interaction? AJSLP, 11 (2), p. 99-110.
Ratner, N. B. (1995).Treating the child who stutters with concomitant language or phonological impairment. Language, Speech, and Hearing Services in Schools, 26 (2), (180-186).
Yoss, K. A., & Darley, F. L. (1974). Developmental apraxia of speech in children with defective articulation. Journal of Speech and Hearing Research, 17, 339-416
Dr. Harmon is an Associate Professor on the graduate faculty at Mississippi University for Women. She currently teaches graduate courses in Fluency Disorders, Phonological and Articulatory Disorders, and Voice Disorders. Dr. Harmon has been an invited speaker in the area of stuttering therapy with state and regional associations and with Northern Speech Services across the country.
