Apraxia Dyspraxia and its connection to autism

Autism is a neurodevelopmental disability characterized by challenges with social interaction, communication, and repetitive behaviors. While apraxia and dyspraxia are not the core features of autism, they can co-occur in autism. The exact reasons for the overlap are not fully understood, but it's believed that shared neural pathways might play a role. And while we don’t know whether all the spoken communication challenges seen in a significant portion of autistics are exactly due to apraxia or dyspraxia, the fact of the matter is that many of us do seem to tick the some of checkboxes of the textbook descriptions of what apraxia and dyspraxia are at an observational level.

For instance, Apraxia is thought to be the result of impact to the part of the brain that plans the movements required to produce speech. You may know what you want to say, but your brain has difficulty in coordinating the muscle movements necessary to say those words. There may be inconsistent speech errors, difficulty in imitating speech and more errors when there are longer sentences or more complex words.

Dyspraxia affects motor skill development. It's not due to muscle weakness but rather a brain-based issue in planning and coordinating movements. So you may struggle with tasks like tying shoes, buttoning shirts, or any activities that require a sequence of movements. Or you might appear clumsy or awkward in your movements when you engage in such tasks.

Again we don’t know if apraxia and dyspraxia by themselves explain all the communication issues seen in almost a third of the autistic population. we don't fully understand how it connects to autism biologically. In other words, we don't know what parts of the brain, neurotransmitters, synaptic connections, and signaling pathways are impacted in those with autism with apraxia and without apraxia. We don't know whether the neurological issues that contribute to someone having autism also predispose them heavily towards having apraxia. Given that 87% of people with autism reportedly have some kind of motor issues, it is highly plausible that they are closely interconnected. 

I think its more useful to use broader terms of what is happening with autistics like "movement differences" or "motor difficulties" till we can say on the basis of real science that the primary neurological condition impacting our movement issues is apraxia or dyspraxia.

Importantly, we do know that communication is a huge challenge and there is an urgent need to not only figure out what is going on but also an equally urgent need for translatable solutions.

 

A better mousetrap is not the solution to communication

NIH came out with this NIOS. I understand this as translating to ton of funding.  https://grants.nih.gov/grants/guide/notice-files/NOT-DC-23-009.html Lot of excitement but everyone thinks it boils down to making better AAC devices. But they are kind of still missing the point.

In fact at a recent large conf, it was all about lets have more AAC, and we need to standardize AAC - folks all excited. Like, Voila, with better AAC, all the communication issues magic away (lots of sarcasm intended) in the minimal speaking autistics. My other takeaway at that conf was that specific groups want to be the monopoly and authority, power jockey, in a future $$$ app that all school districts will be required to buy and it will be applied willy nilly across the board.

I agree that making better AAC devices is important, current landscape is not user-friendly at all which makes them un-motivating to use. You have all these confusing screens you have to navigate and funny looking icons, or if its text based, phrase completion is a mess and so many other issues etc.  etc. So many times, its easier to just not have to navigate it (and communicate) unless you have to. And a $$$ yearly subscription based model feels like someone is holding your tongue hostage for money. I wish the NT population gets to experience what that feels like. 

However the bigger point that folks are missing is that just plopping a better mousetrap (better AAC) in front of an autistic with significant movement/ sensory / somatosensory / body schema issues does not make for effective or faster use of AAC (even the most sophisticated one). 

Building a better mousetrap is a metaphor that is often used ironically to convey the idea that creating a superior product or solution does not guarantee automatic success

We need to also be looking trying to understand the underlying physiological and sensory issues - what’s going on, and then trying to support it and individualize it, whether its medical or technology. If the body is better put together, it can automatically handle the better AAC so much more efficiently.

You only need to communicate some of your waking hours but you need to be dealing with your crazy body every waking movement (and sometimes during sleeping hours too). A more organized body will help on so many fronts. Communication is just the tip of iceberg for the minimal speaking group. 

A Personal Voice

 https://www.thestreet.com/retailers/apple-reveals-a-powerful-new-feature-that-absolutely-no-one-asked-for

This is so cool

Essentially apple is coming out with AI generated feature which will create a text-speech voice that sounds like you rather than a third party foreign voice. 

Maffei et al 2023: Oromotor skills in Autism

Based on review of research published between 1994 and 2022 on oromotor functioning in autistic individuals, 

key takeaways: 

• Oromotor functioning plays a foundational role in spoken communication and feeding.
• 81% of included 107 studies report a significant oromotor challenges related to speech production, nonspeech oromotor skills, or feeding 
• Studies used various methods to investigate oromotor functioning in autistics
• Behavioral measures -  tasks such as tongue protrusion, lip closure, and oral diadochokinesis. 
• Parent report measures - questionnaires and interviews. 
• Medical record review - examining medical records for information on feeding / swallowing difficulties. 
• Neuroimaging techniques -  fMRI & MEG.

• The findings suggest that oromotor challenges are common in autistics, but more research is needed to better understand the nature / extent and their impact on communication and feeding.

Some limitations of this paper include

• numerous inclusion and exclusion criteria, which may have excluded relevant studies eg: non-English publications, pre 1994 studies etc
• wide variation in studies re sample characteristics, behaviors analyzed, and research methodology, which makes it difficult to draw definitive conclusions. 
• did not include a meta-analysis, which would have allowed for a quantitative synthesis of the findings across studies. 

Maffei MF, Chenausky KV, Gill SV, Tager-Flusberg H, Green JR. Oromotor skills in autism spectrum disorder: A scoping review. Autism Res. 2023 Apr 3. doi: 10.1002/aur.2923. Epub ahead of print. PMID: 37010327.

Apraxia, dyspraxia, oral-motor apraxia, Aphasia

[Concepts in Sensorimotor Research]

Pretty much every SLP I've been to over the years, has mentioned these terms. So what exactly are they. 

Apraxia, dyspraxia, and oral-motor apraxia are all related to deficits in motor planning and execution, but they differ in their specific manifestations and underlying neural mechanisms.

Deej

I attended the screening of documentary Deej at UCSF and got to meet DJ Savarese too.
It is quite the journey. The second time I'm seeing the movie. It was screened at Berkeley the first semester I was there. I had reached late so it was nice to see the beginning this time.

A Case Study in the Neural Basis of Communication Challenges

[Concepts in Sensorimotor Research]

An Assignment on Speech and Language 

The chapter on the Physiology of Speech and Language is frustratingly close to home for me as I am severely limited by both my expressive speech and almost very poor handwriting skills (along with other stuff). So I thought I would look at the concepts in this chapter in terms of a case-study of an impacted individual, namely me.

A Case Study in the Neural Basis of Communication Challenges

H is a young adult, who was diagnosed with Autism at age 3. His was a case of regressive Autism in which infants who seem to develop typically and meet developmental milestones,  lose much of their language and other skills soon after the 18 month mark. H exhibits both speech and motor (writing) challenges. This report is an attempt to delineate H’s communication challenges along with the current scientific knowledge about their neural basis.

H’s consistent expressive speech ranges to a dozen or so few key phrases. His articulation may be hard to understand for people not familiar with him.  He can repeat phrases and can sing, though his prosody and articulation are inconsistent.  In receptive language skills, he is well above age cognitively.  He was fortunate to learn typing on an AAC device as a mode of communication which has helped improve his quality of life. What is intriguing in this case is that the subject is very articulate when it comes to written communication, yet struggles with basic conversational speech. H’s communication challenges could broadly be placed under Apraxia of Speech diagnosis though there may be an overlap with other diagnoses related to communication. Since the loss of speech was at an early age, it is often referred to as Developmental Apraxia or Developmental Dyspraxia,.

Apraxia of Speech is an impaired ability to consistently produce and sequence the facial/oral muscles to produce the sounds and syllables required in spoken language. H has reported that he knows what he wants to say but he is not able to sequence that thought into actual speech at that particular moment. He also exhibits other oral-motor skill issues such as challenges in properly chewing food. Studies of brain lesions of patients with Apraxia of Speech provide evidence of impairment in the left precentral gyrus of the insular cortex. Other studies have confirmed the findings that “articulation activated the left insular insula.

Spontaneous talking requires information to flow from the sensory-motor association cortex into the posterior language area of Broca’s area. Then the act of talking itself requires some significant and rapid movement, sequencing and coordination of numerous facial and oral motor muscles (tongue, lips, jaw) along with the vocal chords. Broca’s area along with the inferior caudal left front lobe is implicated in, “memories of sequences of muscular movements used to articulate words,” (Carlson). In addition, Broca’s area is also directly connected to the part of the primary cortex that controls speech muscles. So Broca’s area seems to be a  major player in H’s case.

H does not seem to exhibit significant challenges in the precursors to spoken language - such as perception of present and past events, memories (with some occasional deficits in  short term memory), thoughts and the desire to communicate. Comprehension does not seem to be impacted, which seems to rule out Wernicke’s area as a source of concern. Wernicke’s area is however connected to Broca’s area through the arcuate fasciculus, also known as the Phonological Loop. This connection seems to play a role in the short term memory of speech sounds. H has exhibited difficulty in repeating back  longer strings of words or forgetting the speech sounds of words he’d just read aloud.

There are elements of aphasia involved in that H exhibits anomia (groping for words) in addition to difficulty with articulation.  H likens his word finding difficulty to a, “spotlight effect;”  when placed in a situation where  he is required to speak, adding to the “tongue-tied” result, which in his case is word-retrieval difficulty. If a beginning sound such as the sound “M” is given to him as a prompt, he may cycle through his mental dictionary of words starting with that sound. For example if therapist Michael (vs Michelle) is at the door, H may greet him as, “Hi Michelle,” and a few other names, before arriving at the correct, “Hi Michael.” The word retrieval difficulty ranges from mild to significant on any given day.  H’s history has included EEG’s showing mild disturbances in the temporal lobe. Studies of brain lesions have linked the temporal lobe to the word-retrieval issues.   

Studies have found parallels between spoken language and  written language. For example H, exhibits difficulty in the prosody (rhythm, tone, emphasis) of spoken language which is believed to be controlled by neural connections in the right hemisphere. In his handwriting attempts too, there is disruption in the motor organization of the letters and spacing on the page, believed to be controlled by the dorsal parietal lobe and the premotor cortex. The act of handwriting activates the dorsal parietal lobe, the premotor cortex and the primary cortex.  H exhibits poor motor memory of the motor sequences of space, size and spacing of letters that is required for handwriting. Both attempts at speech and attempts at handwriting therefore are labored and prone to errors. Communication via typing has somewhat simplified the motor aspects of forming letters for H as that requires  keys to be pressed as compared to gripping a pen and drawing letters.

The overarching nature of the Autism Spectrum, with little knowledge of its physiological underpinnings means that there could be many other factors which play into the communication challenges. What is intriguing in H’s case (and frustrating for H himself) is the huge chasm between his motor ability (both speech and writing) and his comprehension and cognition skills.  Basic communication, especially spontaneous speech, is however a critical aspect of daily human functioning and hence its lack greatly affects the individual’s quality of life.  Our scientific understanding of neural workings, unfortunately have not yet reached a level where it  translates into meaningful treatment manipulation.

Psych 22: Biological Psychology

Tablet Education - the iPad Experience

I am from Cupertino in California, the home of Apple Computers and its late CEO, Steve Jobs. Steve Jobs grew up in this very town and started off his company in his garage with Steve Wozniak.  Wozniak was the engineering end while Jobs was its dynamic creative packaging end. From there grew the company that revolutionized computers in many ways and more so the area of hand held devices.

I got my first iMac at age 6. It was a transparent box with a single power outlet, a keyboard and mouse - very futuristic looking and clutter free. I spent endless hours on it going though digitized versions of my favorite books - Dr Suess and Aesop Fables. The message that the slow and steady Tortoise could win over the fast Hare sunk into my mind with surety (from the digitized Aesop Fable, "The Tortoise and the Hare"). The Apple computer took a background for a few years till the advent of the iPod. Suddenly I had hours of music in my pocket, a relaxant and my companion on long plane journeys. The noise of my surroundings could be drowned out by a device that was but a few square inches. The iTouch was the next, it was exciting as I could now play games and it even had a small keyboard that I could type on. And I still had access to all my music.  Along came the iPhone, and with it the power of reaching out and talking to others.

The finale was the iPad - a computer you held in your hands - an electronic tablet. It didn't require a lot of booting time, and it was simple to use. You could do most things on it that you could do on a regular computer. A touch screen meant that you did not need a mouse or a keyboard. You could type documents and browse the internet.  There was an app for everything. Games were the first and they took on  new level with touch-screen technology. Best of all it opened up a world for communication for those who desperately needed an avenue. There were text-to-speech apps, which gave the voiceless a voice.  There were sentence and icon apps which helped bridge communication for those who lacked it. The world was potentially at our very fingertips. We could learn anything - there were no limits to educational and other possibilities. What a great equalizer for the world that is usually divided by access and abilities.     

In the end, the camera and other fancy add-ones that a gadget provides are secondary. The fact that it starts to make a difference in the lives of many, and gives them new direction and hope, is what makes it remarkable.

Steve Jobs recently died of Pancreatic Cancer. We will miss you, Steve Jobs, Cupertino's own son. You put this little city, which was once just orchards, on the world wide map. Most of all, your products truly made a difference in the lives of many including me.

Prof Stephen Hawking

On a person who represents the theme “Life is a Challenge, Meet it”

Prof Stephen Hawking

Prof Stephen Hawking is one of the world’s brilliant theoretical physicists. Like other great scientific minds, he has worked on the basic scientific laws that govern the Universe. His work on black holes has especially been path-breaking.  His work has resulted in the unification of Einstein’s General Relativity and Quantum Theory, which is a significant development in that field. Some of the conjectures from his work are that black holes are not really black and that the universe has no boundaries.

Sound familiar?  Swami is Kalathithaya – beyond space and time and limitless. How then can the universe have boundaries? Science is just the ‘explainable’ component of spirituality.

Stephen Hawking was born in Jan 8, 1942 in Oxford England. You could say the first two decades of his life was fairly uneventful compared to the latter half. In a nutshell

-    His first choice, math, was not available, so he took up physics in college.

-    He was not a great student, with borderline marks – he needed a makeup oral exam at one point to pass.  

-    He did not read much and did not take notes either in college. 

He started to develop atypical ALS at around age 19. He started off by being increasingly clumsy. ALS is a degenerative motor-neuron disease, where the patient progressively loses neuro-muscular control. Most patients don’t last more than 10 years. He did not know if he would live to finish his PhD.

After an initial bout with depression, he decided “if I was going to die anyway, it might as well do some good”. He went on to finish his PhD in Cosmology, married and got a fellowship at Cambridge. 

In a way he says he was fortunate to be in the field of theoretical physics because “ that is all in the mind. No physical ability is required”

It’s been a good 40 years since he was diagnosed!!

Some of his notable achievements in the scientific field

-    From 1979- 2009, he has held the post of Lucasian Professor of Mathematics at Cambridge University. This is a position held by Isaac Newton.

-    He has authored several popular books and TV shows, to make the subject accessible to the layman- A Brief History of time, The Universe in a Nutshell, Black Holes and Baby Universes, Into the Universe etc. 

-    He has won numerous distinctions and awards all across the world. 

In his personal life, his first wife divorced him due to the pressures of his care. He then married his nurse but they too divorced a few years later. He has children and grandchildren. 

His condition has affected his physical ability unevenly. Till around 1974, he could take care of himself, after which he needed help from a live in graduate research student. From 1980 he had a system of nurses. In 1985 he had to undergo a tracheotomy operation, after catching pneumonia at the CERN facility in Switzerland. He has needed 24 hr nursing care since, which has been funded by grants.

Even prior to the operation his voice had started slurring. In many of his public speeches prior to 1985, his graduate assistants were interpreting for him. 

But after his operation, he lost his voice completely. He had to find a way to communicate. Walt Woltosz offered him a software program called the Equalizer. Words could be selected from menus on screen by pressing a switch. And a sentence was slowly built up. He typed at approximately 4 words a minute this way. 

David Mason of Cambridge Adaptive Communication adapted the system to his wheelchair and used the 1980s telephone answering system to convert text to speech. The voice was robotic, with an American accent, but it’s the voice, that Stephen Hawking identifies with, and still uses.  

In his words: "A cursor moves across the upper part of the screen. I can stop it by pressing a switch in my hand. This switch is my only interface with the computer. In this way I can select words, which are printed on the lower part of the screen. When I have built up a sentence, I can send it to a speech synthesizer. 

I can write equations in words, and the program translates them into symbols. 

I can also give lectures. I write the lecture beforehand, and save it on disk. I can then send it to the speech synthesizer, a sentence at a time.” 

   

On TV shows, his voice output appears to be smooth and fluent only because it has been pre-prepared. At live conferences, it can take him up to 7 minutes to answer a question. 

Hawking lost the fine motor control of his hand as well and could no longer press the switch. Again the software had to be adapted. A small infrared sensor was attached to his glasses. The sensor detects intentional cheek twitches and triggers the switch. 

Using this he selects words, one letter at a time and slowly builds it into a sentence. 

Just imagine it - This is the system he has used to write his books, TV shows, give speeches, attend conferences and do his scientific work. 

This computer system also allows him access to remote controlling things like music, TV, lights, voice over IP, and opening doors in his house to allow him more independence.

His computer system has to be pretty much be replaced every year and he is fortunate to have the support of tech companies like Intel who are willing to invest in helping him. It has also helped that the onset of his illness came about slowly so he had time to establish his brilliance and intellect instead of trying to prove his cognitive abilities in addition to the struggles to communicate. 

Stephen Hawking essentially went beyond the bodily human limitations and reached out into the infinity of space. He even went on a space flight recently and experienced weightlessness. What a relief that must have been – not to be weighed down by the physical body. 

What if Stephen Hawking had been born 40 years earlier, when such technology was not available?  His mind would be lost to the world - what an incredible loss that would have been. Technology really has been a blessing in disguise for him and many who have no other avenue of communication.

His life was and is still a challenge. Yet he continues to face it and has overcome it in many areas. 

Efforts are being made to develop systems that will help him communicate should his face become paralyzed as well. Perhaps one of us will be in this field where we will develop new and affordable technologies that will benefit many people all over the world. 

Does not Swami keep telling us that we need not be trapped in the illusion of the insignificant physical body? Seems to me that Stephen Hawking has kind of done that.  

I like the answer Stephen Hawking gave on his site: “The human race is so puny compared to the universe that being disabled is not of much cosmic significance.” 

Lessons learnt. 

Stephen Hawking’s life has been a great source of inspiration to me.  Especially the fact that he’s done most of his work at the rate of 4 words per minute. That is the epitome of perseverance and dedication. 

I’m sure there is some element of frustration too – I can relate – it’s faster to talk that to type out a thought letter by letter, word by word, sentence by sentence.  A mind like his must be churning out thoughts faster than the physical movement of his cheek muscle. 

Life is going to be challenging whether or not your physical body imposes limitations. But you can still move beyond and make it less of a limitation. And you have to move others with you and take all to greater heights of human consciousness.

When challenges come your way, hold fast onto Swami’s hand and walk with Him. 

Sources: 

Official website of Prof Stephen Hawking. 

http://www.hawking.org.uk

Saenz, Aaron “How does Stephen Hawking Talk” (5/3/10)

http://singularityhub.com/2010/05/03/how-does-stephen-hawking-talk-video/