Praxis and Language, do they co-exist? If they do, how do we understand this in every day sessions with every day caseloads? Do we talk to the children we have in our therapy rooms? How do we know what they are hearing, how they are listening to our language? How do we know they are not responding due to not being able to sequence language, or not being able to plan a motor sequence? These are interesting questions, are they not? To answer them requires a certain amount of self-reflection, especially to ponder the multi-faceted child in all his or her wonderful ways, including their challenges.
What is Praxis?
Let’s first understand praxis and be sure we all carry the same understanding. Praxis entails multiple different components, built on several building blocks of foundation, which has to be accomplished in order to acquire the skill of praxis. As a definition, praxis contains the ability of the nervous system to ensure a timed, coordinated response from the motor system of the body, while also contemplating how the limbic system (emotions) feels about it. Without this function, we potentially feel helpless, as if we have no power, no way to enact upon this world and many times, the only recourse we have is the Amygdala in fight, flight, or freeze, because it does not require sequencing, simply a reflexive response. In fact, praxis is what gives us planful, executive behavior.
Praxis is built on the foundation of having the ability to regulate (modulate) our different senses. If our nervous system is disorganized, it is very difficult to built planful behavior, as praxis requires a calm state in the nervous system. It also relies very heavily on our ability to discriminate with our different senses, so we know how hard to push a cart, how to feel what we hold in our hand, how we see the object in the distance we see it, and how we hear the instruction given to us. The ability to register information and process it to the brain to be analyzed, is the cornerstone upon which we can build constructive play that would contain purpose and meaning, and result in planful behavior. Without these building blocks, we will struggle to achieve the multiple forms in which praxis occurs.
The totality of praxis relies on first having a motor idea, initiating this idea, sequencing through the idea, and to culminate in completing this idea within the same timing and rhythm as our peer. As we complete the activity, our body also registers feedback that supports us to repeat that action. Feedback is important for self-motivated (intrinsic) repetition, such as you see the new toddler do when they pull themselves together after taking the first step to attempt the second step. An amazing process to watch unfolding in front of our eyes and no parent is more proud of witnessing this moment.
As praxis develops it proceeds into higher forms of organization, which occupational therapists consider as the “Bilateral Integration and Sequencing” profile, which requires both sides of the body to do all of the above processes of praxis in more precise timing and sequencing. These periods of development in higher order thinking has much to do with co-existing processes of thinking/planning with inter-hemispheric organization between left and right brain. This sets up the ultimate goal of having great executive functioning skills, which would include timely responses from all senses at the same precise timing leading to having adequate ability of being a functioning school student that embraces learning.
The importance of occupational therapy being involved in this process cannot be understated. I have witnessed multiple times that as soon as the “behaviors” are under control and children can form a semblance of writing potential, they are discharged from services without considering this in the fullest extent and then we are surprised if the family calls us a year later that similar “behaviors” have resurfaced again. An interesting exercise would be to video tape your Sensory Processing session and view it later with no sound and simply watch the complexity, or lack there-of, in how the child moves. Yes, they have all the muscles, but have you really observed how they seem to use the same motor sequence over and over again, or how much they try to rely on language to see a play scene through.
Communication is more than verbal language
Which brings us to the thinking around language and praxis and their co-influence on each other. It simply does not seem right to discuss language as in only the verbal format as much “language” co-occurs with central nervous system in the first year life before verbal language starts occurring in typical development. It is essential that we first consider non-verbal communication as therein lies much of the difficulty with our kids that also exhibit praxis difficulties. It is the primary job of the infant to cultivate increasingly complex non-verbal gesturing to support the meaning and context of what is to develop in verbal skill later. If the child is experiencing poverty in their ability to plan their movements, we have to consider the impact this would have on their ability to use gestures. It is a well-known fact that communicating a clear message depends 80% on your non-verbal communication to each other. It is what supports the meaning of context and without it, you become no more than a “talking head”. These children develop into kids who rely so much on facts and what they can grasp in black and white, that the underlying meaning, the different social nuances become lost on them. It becomes a sad world in which it becomes increasingly difficult to connect with others and no amount of social skills classes can replace the exquisite automaticity that this requires from our system.
During the first three months of life, as we are working incredibly hard to set up our regulatory system and establishing firm bonds with our caregivers through our senses, communication is all about the senses. Listening to the mother’s voice in typical circumstances is soothing and flexes the baby’s ear muscles to receive sound in certain frequential patterns. These patterns is what supports voice modulation, or prosody, later in development. The closeness and bond of mother / father to child, sets up the intent to communicate, simply because of an innate wiring to want to relate to the one you love most in the world. When children have regulatory difficulties, this bonding is affected, which also affects the communicative intent and co-reciprocity of contingent communication so beautifully observed in parents who engage in the delightful “motherese” voice.
The central nervous system has a great many functions to accomplish during this important building block. The baby has to achieve the ability of a self-regulated state with cycadic rhythms. She has to learn to maintain visual gaze upon the close caregiver interacting with her. She learns different cries to communicate to the mother that a certain need has to be met. She is also learning the important suck-swallow-breath synchrony that supports regulation and receiving nourishment from the mother.
The next stage of communicative effort includes the ability to co-regulate with an innate sense of timing with the caregiver, which becomes a building block for the timing that comes with motor coordination later. It is established with great reliance on the co-reciprocity of the caregiver. The baby is learning to initiate communication through gesturing alongside their first initiations to reach for a colorful object, to want to roll over, to get into the rocking for a crawling position. The baby also learns during this stage to modulate her emotions in the secure base of her relationship with her mother and experiences the different occurrences of different emotions, their intensities and their durations. This experiential phase is mostly limbic (emotional) to physical (central nervous system) and heavily reliant on the central nervous system to regulate and register this information. The baby is making her first efforts to combine eye gaze with gesture, facial expressions and sounds, mostly to gain attention. She starts vocalizing pleasure and displeasure and uses many different speech sounds in babbling. These sounds include p, b, and m, with increasing frequency over longer spans of time. You can hear the baby chuckling and laughing with you, as well as making gurgling sounds as they exercise their ear muscles for the reception of language in order to prepare for producing it later. During this phase, the importance of registering facial information to prepare for the oral motor planning becomes crucial. It always saddens me when we have children with praxis difficulties, who are trying to speak, but cannot formulate the words and they become frustrated and stop trying. Emotionally they do not feel “felt” because they do not have a way to express themselves verbally and we are missing all the important non-verbal cues, as well as ignoring the facial muscles in getting them ready to register motor movement patterns for oral motor planning.
The next phase still occurs in the first year of life and becomes crucial to effect a two-way engagement of conversation. The baby now increases in intentionality in the use of non-verbal communication or gestures. She starts being able to discriminate the mother’s actions from her own and maintains ongoing moments of shared intensity with meaning. She starts to understand cause and effect, which is very important for the will to enact on praxis, as she also engages in multiple exchanges of back and forth communication. This contingency of communication is very reliant on those initial stages of building praxis as one step is followed by another step, continuing to build from the starting point. Babbling at this stage contains of both long and short groups of sounds such as ‘tata, upup, bibibibi”, signaling the beginnings of speech like intonation. Children diagnosed with Verbal Apraxia frequently have great difficulty with this area and can remain stuck here for a very long time. Occupational therapists can be very supportive of speech language pathologists in supporting the whole body to receive and register information as well as plan execution. It is very seldom that children with Verbal Apraxia do not also have a co-responding praxis difficulty in the body.
During this phase the baby starts to use speech or non-crying sounds to obtain and keep attention. She starts to wave, to hold her arms to be picked up, all of which are very reliant on the different aspects of praxis described above. She starts to imitate speech sounds and works on developing the coordination between motor initiation and sequencing with timing. By her first birthday (could be as early as 9 months for some, consider range of individual profiles of typicality) she is heard to say her first words (hi, dog, dada, mama), though sounds may not be exactly clear.
The next phase of development is really where every parent of a special needs child wants us to be. It is about developing speech and using language in speech. For this important phase of development we need to continue including the essence of relationship because if there is limited exposure to quality relationships, the child does not exercise any communicative intent, limiting the exposure to using gestures as well as communicative expression in its myriad of forms. Children do not point to objects, if there is no one available to see it. During this phase the motor planning development accelerates in ideation, initiation and sequencing. The baby wants to explore the world, be curious and act on it, will crawl away from caregiver, look back at the sound of the mommy’s voice. She starts developing her physical sense of Self and physically being in the space she occupies, learning more about the differences between herself and her significant others. She also learns how to influence others, which requires flexibility of her physical system to negotiate different motor ideas. If she struggles with praxis the exploration is curbed and her communication through behavior frequently is labeled as being rigid or even manipulative. She does not have control over her environment and does not have the necessary motor plan to follow through on her ideas. Her language, her communicative intent is inhibited by a primary need for a secure base, a place of comfort, a place where she can self-protect.
If all is developing typically she communicates with increasing vocabulary first in single words, then phrases, then sentences. These language milestones are particularly sensitive to understanding sequence in the body. In order to formulate your own language, you have to understand at some level that one “thing” follows on another and that there is order to it. Children who use echolalia are particularly prone to have difficulty with praxis, more specifically with sequencing. At some level they understand the need for a sentence structure, but they have to “borrow” from someone else’s speech through memory in order to communicate, as they simply cannot structure their own sequence.
Bloom and Lahey Model
Speech Language Pathologists frequently discuss the language model proposed by Bloom and Lahey, which explains three components of language: Form, content and use. The Form of language is the tangible part. It consists of the phonology (sound), morphology (different morphemes in words), and syntax. It starts with single words, develops into two word phrases, adding plurals, and then culminates in the formation of sentence structure. This process is very reliant on sequencing, though there are two forms of sequencing available to the speaker. The sequencing that involves the body and timed execution of gestures simultaneously with speech, is one aspect. The other form of sequencing is understanding logical order through the cerebral cortex with intelligence and utilizing memory to support development in language. So it is possible to use language and become a fluent speaker while still experiencing praxis difficulties in the body. This type of speech development though often is very bound to intelligence and though the speaker can maintain fluid speech on a topic, the speech might lack the prosody and tonality of voice modulation, and the rhythm of a back and forth communicative effort. Such persons may also have difficulties in social skills as the speaker has not developed the integration of gestural and verbal communication causing a lack of understanding in hidden and abstract meaning.
This brings us to Content part of their model, which includes meaning expressed through words. In terms of language development, it also contains the development of action words, location words, and descriptive words. Children struggling with praxis have difficulty figuring out the “how to” of things and pairing physical problem solving with action words is a frequent technique to use in sessions. Location words are frequently used when considering the visual-spatial experience of the child, especially when directing the body through the space they find themselves in. Descriptive words are dependent on the child’s ability to take in (to process) all the physical properties of the object through all their different sensory systems. To further describe different ideas to do with the object in hand also requires ideational praxis and the ability to initiate a plan. Thinking about this in a therapy session, we need to consider the difference between intellectual (cognitive) problem-solving and problem-solving through the body. The body developmentally precedes cognitive development and it is very important to make this distinction and for the therapist not to be “fooled” into thinking the child is efficiently doing this, when you need both scenarios to be fully integrated.
The Use of language is the third component of the model. The child has to understand why she is communicating, which involves an abstract formation of having meaning to communicate. Frequently parents are so proud of the words and sentences their child can repeat back or use when prompted. This expression frequently does not come from the place of meaning. Using language is one aspect, communicating with language is the fuller aspect. The sense of purpose and goal directedness behind her language is reliant on the building block of abstract formation and ideation, which is formalized through the use of sequential order. The communicating child has to understand the concept of sharing, and when to request more information, which is a very integrating process requiring that inner timing and reciprocity that was discussed earlier. The multi-tasking layer added to this is being able to ideationally follow the context of the communication, which requires much active working memory that again is constructed through the timing between the auditory and visual-spatial systems. Finally, she needs to be able to find her cues from the environment she is finding herself in, which requires so much processing from all her systems.
One of the important milestones at team meetings to consider is the child’s ability to ask and respond to “why” questions, which inevitably implies the child has access to logic. Logic is formed by understanding the sequential order of things, which again is built on praxis. In mentoring therapists, I frequently propose not to move on to “why” questions before we know she is solid on “how” questions. This way we know we are using the body to sequence and to problem solve, which avoids compensating with cognitive skill and reinforces integration.
Language comprehension relies on all of the above and is greatly dependent on active working memory, which jointly ultimately will lead to reading comprehension as a student. Again here, we need to distinguish between cognitive ideation in language and ideation through the motor system. Motor ideation leads to creativity in finding flexible different options to move around or through an obstacle. Cognitive ideation leads to using the intellect in creativity in coming up with multiple different ideas. The more experience the body has in being able to flex the muscles in different directions and ideas, the more the cognitive brain will be able to integrate their cognitive skill with practical problem-solving skill that requires the ultimate skill of integration.
We also need to focus on the role of timing in the two different aspects. Timing in praxis supports the coordinated effort of body and limbs in order to play sports, move around obstacles, to name only a few. But it also sets up the timing that is necessary so she could look and listen to you at the same time, which is what every effective communicator would need to do. There is also a certain timing in the prosody of language that supports intonation, which in turn supports the meaning behind the verbal message. The very act of reciprocal communication has a certain sense of timing connected to wait and listen, then speak when it is your turn. Finally timing is also involved in delayed gratification in that she has the ability to keep in working memory her message until the other speaker is ready to hear it and not be impulsive about it and “insensitive” towards the other speaker.
Language conveys Meaning
Which brings us to the final point to be discussed in this essay. Language has to convey meaning. Meaning has to have some connection with the speaker. The speaker is emotionally involved in the message, otherwise would not be intrinsically motivated to even formulate it. This emotional connection holds symbolic meaning for the communicator, which is only derived through plentiful experiences of play. Play is where the young developing child works out all the different experiences and files away all the meanings of different emotions in order to integrate it with language and cognitive thinking. The problem is that many children with developmental needs have not had nearly enough learning experiences through play because of their praxis difficulties. While playing, we learn to have an effect on the beginning, middle, and end of a story and the order in which the sequences occur. Children with compromises in praxis frequently struggle with emotional developmental delay, which ultimately also effect the content and meaningful use of language.
The real story is that it is all interconnected. With what we know as therapists today, we simply cannot intervene in a child’s life in isolation any longer. We need to bring a team around each child that will consider the different goals of the child in a way that would respect the child’s entire profile in order for her to become intrinsically motivated to turn towards learning and simply… fly!!!
Maude Le Roux, OTR/L
September 2016 – SAISI Journal, South Africa