Our guest hosts tonight, April 16, 2001 are Dr. Marilyn Agin, SLP, MD, and Lori L.  Roth, MA, CCC-SLP, who are both part of the volunteer professional staff of the CHERAB Foundation, a personal support source for apraxic and language disordered children and their families. They will
be chatting tonight about childhood oral/verbal apraxia.

Prior to medical school, Dr. Agin received her master's degree in
Communication Disorders and was a practicing speech pathologist
treating children and adults. Subsequently, she completed a combined
residency in Pediatrics and Physical Medicine and Rehabilitation at
New York University Medical Center and the Rusk Institute. She is
board certified in both fields.

As a practicing pediatrician, Dr. Agin was a keen observer of normal
development during the well visits for young patients.  She would
often identify children with speech and language disorders, including
apraxia of speech, neuromotor delays, sensorimotor dysfunction, and
children on the autistic spectrum.

Currently, Dr. Agin is the Medical Director of the Early Intervention
Program for the city of New York-the biggest program of its kind in
the country.  In addition, she treats developmentally disabled
children in a clinic setting and does private neurodevelopmental
evaluations for children of all ages.  She is passionate about early
referral for developmental delays and disorders and has lectured to
other Pediatricians and participated in numerous workshops on
developmental surveillance, screening and assessment.  She is a member
of the New York City Chapter of the Committee on Children with
Disabilities of the American Academy of Pediatrics.

Lori Roth is a Speech Language Pathologist/ Oral Motor
Specialist with over 25 years experience. Ms. Roth has practiced her skills in
various settings including the public schools and early intervention
programs, but has always been focused on oral motor skills and verbal
apraxia. Ms. Roth currently has a full time private practice.
She regularly presents workshops in Oral Motor Skills and
Articulation, as well as participates as an active Board
Member for the CHERAB Foundation/Children's Apraxia
Network. Ms. Roth is coordinating research projects presently
being developed by the CHERAB Foundation with the hopes
of finding effective treatment tools, dietary
supplements and diagnostic tests for verbal apraxia in

<Robin> We are very pleased to welcome Lori Roth and Marilyn Agin as our chat hosts
<Robin> they are both part of the volunteer professional staff of the CHERAB
    Foundation, a personal support source for apraxic and language disordered children
    and their families
<bilingualslp> is there a way to subscibe to the organization's newsletter?
<Marilyn Agin> We do not have a newsletter
<Marilyn Agin> We have a grouplist thru yahoo
<bilingualslp> i guess all the info is on the website
<Lori Roth> yes. www.apraxia.cc
<Robin> Deb, just go to the www.apraxia.cc website for listserv info
Lori Roth> Are there any questions about verbal apraxia that we can answer for the  professionals?
<Robin> have any of our chat participants worked with apraxic children?
<bilingualslp> yes I have and I guess I have questions about differential diagnosis
<Lori Roth> Has anyone taken a PROMPT workshop?  Differential diagnosis is found on the apraxia site.
<bilingualslp> I have worked with children who appear to have the diagnosis-there  have been times when I was not sure-
<bilingualslp> no I have not taken PROMPT
<Robin> what characteristics made you think the children were apraxic?
<Lori Roth> Let me say that there are at least 7 symptoms(?) that point to apraxia vs.  other speech disorders.
<bilingualslp> I would be curious to hear about those 7
<Pamela> I have a 3 year old at the CV and VC level that repeats her words in a high   pitched voice.  Is this common? 
<Lori Roth> 1. Significant difficulty imitating or producing on command oral motor  movements (with sound).
<Lori Roth> 2. Inconsistancy in reproducing these movements.
<bilingualslp> ok so far I have been on target-what is next?
<Lori Roth> 3. Difficulty producing sounds in sequence even when the phoneme is produced in another word correctly and with no difficulty.
<bilingualslp> I have 3 kids that demonstrate the above and can think of others-
<Marilyn Agin> there are also neurologic signs on the physical exam
<Lori Roth> 4. breakdown in sound accuracy as strings of words increases in length.
<bilingualslp> inability to program the speech sound movements-this is what comes to mind when I think apraxia
<bilingualslp> I know the definition is broader and is more descriptive
<Lori Roth> inability to recall or pull up the motor patterns except in overlearned patterns.
<bilingualslp> by pull up you mean access?
<Lori Roth> yes. Remember there are also soft signs usually visible. SI, for example.
<Robin> Marilyn, perhaps you can also elaborate on the neurological signs
<Marilyn Agin> children will often have truncal and oral hypotonia and sensory integration dysfunction
<Lori Roth> Oral motor apraxia can be accurately diagnosed by 18mo. through feedin  difficulties. Verbal apraxia can be diagnosed after 3yrs.
<bilingualslp> this helps-limited diet and food refusal related to either?
<Marilyn Agin there  is often a history of resistance to increased textures
<bilingualslp> but not absolute food refusal?
<Lori Roth> yes. In fact these children prefer strong tastes. Peppermint toothpaste, pickles, lemon juice, and as Marilyn said, resist new food textures.
<Marilyn Agin> have you had med professionals in your locations make this dx?
<<bilingualslp> I have at times in NY particularly in childrens hospitals and in home
    care, nursing
<Lori Roth> Where children grow through periods of acceptance (windows of
    opportunities to introduce new textures and tastes)
<Lori Roth> these children get stuck early on.
<shelly> I have a question about service delivery .  I work in early intervention and would like to know how you can treat apraxia which requires such intensive treatment
    in just one one-hour session per week
<bilingualslp> I am thinking the same
<shelly> At what age would you recommend outpatient/clinical model tx?
<Lori Roth> Interesting question. Do the best you can. Set up a home program.
<Marilyn Agin> In NYC children can get tx 4x wk
<bilingualslp> that must have changed-when I lived there-4 times a week was
    unheard of but this is great
<bilingualslp> when did that start?
<bilingualslp> treatment that often-is that only for a diagnosis of apraxia?
<Lori Roth> Each state uses the 2 hours max. differently..but in NJ we can get 4 1/2
    hour of therapy sessions weekly.
<Pamela> What information does insurance require by the referring physician? Drs. do  not know about apraxia here.
<shelly> we have had a rather large HMO in our area just cut speech therapy benefits  entirely for children unless "medically necessary"  Any of you with similar problems     and if so, any suggestions for parents?
<Marilyn Agin> If you give the proper dx code with a letter of medical necessity you  can usually get payment
<Lori Roth> Marilyn has a wonderful response in the archives of the CHERAB
    Foundation adddressing just that. Join the www.apraxia.cc listserv and search it out.
<DebbieG> a young child with apraxia should be able to get therapy thru the county or  school district and not need to go to an HMO.  Right?
<Marilyn Agin> Debbie, that is if the child is over 3
<DebbieG> A child birth thru 3 can get services thru the county here
<shelly> would a physician typically write a letter of medical nec?? for apraxia dx?
<DebbieG> I don't think a Dr. would write it up as medically necessary
<Lori Roth> why not?
<Pamela> Dr. Agin, I read your statement about dealing with insurance.  I used the  code 781.3  Coordination difficulty.  Can this apply to speech musculature only
    and not gait?
<Marilyn Agin> Pamela, yes it can
<Marilyn Agin> I have used this dx for apraxia of speech
<Marilyn Agin> Also 784.69
<shelly> Birth to three programs are "family focused" models and getting funding for  sessions to work one-on-one with the child more than one time per week is usually  difficult
<Lori Roth> This is not an educational developmental disorder. It is a medical
    neurological disorder.
<Pamela> Any quick, easy resources to provide physicians or insurance that this is a
    "neurologic" disorder, not developmental?
<Lori Roth> Why shouldn't parents get their tx paid for by their medical insurance?
<Marilyn Agin> shelly, it depends on the EI program
DebbieG> Yes.  EI program where I am always gives one-on-one services 2 to 3
    times per week
<shelly> what state are you in Debbie?
<DebbieG> NY - Long Island
<Marilyn Agin> NYS seems more progressive
<shelly> Lori, if it's a neurological disorder, why wouldn't medical insurance cover it
<shelly> I don't understand?
<Marilyn Agin> Some med plans have criteria for neuro involvement
<shelly> I think this HMO in particular is looking for a way to save money
<Pamela> So how do we get across to insurance that it is neurological? Do the
    children need to see a neurologist?
<shelly> Many parents and providers are upset to say the least
<Marilyn Agin> You can also see a developmental pediatrician
<Lori Roth> Children that you suspect are verbally apraxic need to be evaluated by a
    developmental Ped. or Ped. Neurologist familiar with apraxia. The CHERAB
    Foundation is presently gaining referral sources
<Robin> that would be great to have a data base of dev. pediatricians
<Lori Roth> Marilyn is instrumental in educating her collegues.
<Marilyn Agin> I was able to convince the Med Director of  Aetna/ USHC to give a child 5x
    wk sp tx for 3 mos
<Robin> Marilyn, are your colleagues receptive to your help?
<Marilyn Agin> Some are but many are dubious
<shelly> can't SLP's make the diagnosis??
<Lori Roth> Not if we want the neurological disorder dx.
<shelly> yes, good point
<Lori Roth> We cannot or should not dx a neurological disorder without the medical
    professionals substantiation.
<Marilyn Agin> shelly, yes, but I think it helps to have a medical dx for insurance
    purposes and to rule out other syndromes.
<Marilyn Agin> have any of you recognized apraxia in the autistic population?
<shelly> Do you typically not dx until age 3 and why?
<shelly> I have two who demonstrate s/s of apraxia at age 30 months
<Marilyn Agin> In some cases you can make the dx earlier
<Lori Roth> Phonological disorders, and latetalkers often display similiar
    criteria...Since by age 3 children should be speaking in 2.5 words (and that's low
    balling the range) words per utterance
<Pamela> Is it possible to be verbally apraxic and produce a string of vocalizations with
    intonation but not clear sounds.  She can't say two syllable words unless it is repetitive
<Lori Roth> Pamela..you're exactly correct. Here the child can produce a word with rep.
    syllables but change a vowel or consonant and everything breaks down.
<shelly> Marilyn, what signs do you look for in a neurological exam?
<Marilyn Agin> Shelly, a history of feeding problems, low muscle tone for starters
<Lori Roth> Many children cannot produce a 1 syllable word without adding a vowel at
    the end. stop becomes stopah
<Marilyn Agin> these children usually have motor planning problems like limb apraxias
<Lori Roth> Have you seen your kids slouch in their chairs, continue drooling when
    they are no longer teething, or continue to munch through food instead of
    demonstrating a more mature chewing pattern?
<shelly> what about attention difficulties??? I have one little guy who will not make eye
    contact or watch my face for cues unless I physically hold his chin and then attention is
<Pamela> I am with you on that one shelly
<shelly> also noticed that he does not have independent movement of tongue and
<shelly> that is, /l/ sound made with vertical mand. movements
<Lori Roth> Yes that too...Just because these children are apraxic doesn't mean that
    they don't also show signs of other learning difficulties. Do the kids you have look too
    serious too?
<Marilyn Agin> Yes, sometimes their self esteem is affected early
<Pamela> yes, one looks serious
<Pamela> I know that can be a sign of oral apraxia but she seems to imitate oral
<Lori Roth> Can these children smile on command?
<shelly> yes
<Pamela> I'll have to test. I just remember testing the tongue movements
<Erika> ...am I late?
<Robin> our students will be joining us soon
<Erika> ok
<Robin> hi Erika...no you're not late...we're winding up our prof. chat...getting ready for
<Erika> oh!
<Erika> carry on!
<shelly> one of my clients says sha sha sha for everything and has a great deal of
    difficulty even at the cv level
<Anonymous3631> I'm noticing a recent increase in referrals of children in the 18-24
    month age range, wtih oral and/or verbal apraxia:  many of them were delivered with
    suction applied to their heads.
<Anonymous3631> does anyone have any info on this?
<Anonymous4835> Hello.  I am new to this process of chatting.  I am interested to see
    what is being discussed.  I have a three year old son diagnosed with apraxia
<shelly> I'm wondering why, at 30 months he is not processing that he is not saying
    "true" words
<Robin> Do you recommend any specific test batteries to evaluate verbal apraxia??
<Lori Roth> As far as the tests are concerned...I use a receptive voc. test, a general
    language test where I focus on the receptive language area then evaluate oral motor
    skills and sounds Kaufmann Test of Praxis
<Pamela> Dr. Agin,  is there any connection to delivery problems and apraxia?
<Marilyn Agin> Not necessarily
<Marilyn Agin> I've heard of perfect deliveries and apraxia
<Marilyn Agin> So far we have not been able to come up with consistent neurologic data
    for apraxia
<Robin> 4835, is your son in therapy now?
<Robin> welcome all!  we will be starting our student chat in a few minutes
<Robin> we are chatting tonight about apraxia with our guest hosts Dr. Marilyn Agin,
    SLP, MD, and Lori L. Roth, MA, CCC-SLP
<Anonymous4835> My son has been in therapy since 18 months of age.  He was
    receiving speech 5 times per week but is now down to three times per week. 
<peg> I am an experienced practicing clinician
<shelly> peg, where do you practice?
<peg> Charlotte, NC
<Jamie> anyone from Philadelphia?
<Marilyn Agin> I have just changed computers, but I am here
<Anonymous8914> Peg, I just received a contact for help in your area if you are
    interested.  Is Oakboro around you?
<peg> I'm not sure how far it is.  I'm sure it's a distance (within an hour?)
<peg> I  can handle it, in another 4 weeks or so.
<peg> Call Presbyterian Hospital:  704-384-6631 to get me.
<peg> Once the children hit age 3 I have to give them up to the schools, can
    someone tell me how they do after this?
<Anonymous8914> Peg, I'll give them your number at the hospital-Thanks!
<shelly> peg, we were discussing insurance coverage earlier.  I would definitely refer
    them for private speech therapy because I don't believe they will get the intensive
    therapy they need in the school system