Causes, Signs and Symptoms, Diagnosis, Treatment, and Prognosis of Childhood Apraxia of Speech
Childhood apraxia of speech (CAS), also called Apraxia of Speech (AOS) or developmental apraxia, is an oral motor speech disorder. Children with CAS find it difficult to produce the sounds they want to make because they cannot correctly plan the movement of the muscles that control the articulators (lips, tongue, teeth, jaw, and velum). Note that poor motor planning is not referring to weakness or paralysis of the muscles. Typically, our brain sends the movement plan to our speech muscles once we have decided what to say. In CAS, though, the child’s brain does not send the proper instructions to the muscles used to adjust the positioning of the articulators and the speed and rhythm of the speech. If the brain signals are not transmitted correctly, then the child’s speech movements will be difficult to coordinate, resulting in unintelligible speech.
A short lesson on motor planning: Speech is a quick process, but a lot of motor planning is working behind the scenes. Think about the way we say consonants. You may be thinking of consonant letters, like B, C, D, and F. However, in speech, the consonants are actually sounds (written inside of forward slashes such as /b/ for the B sound) that are created by the articulators as they control the air that is released from the lungs. For stopping consonants, we stop the outgoing air by closing off the air stream with our lips, tongue, or velum. Try it now. Say each of these consonants slowly: /b/, /k/, and /d/. Notice how your tongue and mouth move for each letter compared to when you say the vowels A, E, I, O, and U. Vowel sounds require a lot less movement.
Now imagine only being able to speak in vowel sounds. Say this sentence while skipping the consonant sounds: “Hi, my name is Jane.” The result is an unintelligible speech like that of a child with CAS. In fact, some children with apraxia struggle with saying vowel sounds as well as consonants. A skilled speech-language pathologist is required to identify the level at which the child’s speech sounds are affected by poor motor planning.
It is important to note that children with CAS may have a combination of other disorders, such as general apraxia that affects the movement of the whole body, but they may also have otherwise normal language skills despite their troubles with producing speech.
CAS is not a very common disorder, but even more frustrating for parents, it is often diagnosed without a known cause. The following conditions are thought to cause, or at least contribute to CAS:
Congenital disorders. Conditions that are present from birth, such as genetic disorders and syndromes, may result in faulty wiring of the brain’s signaling system.
Acquired disorders. Trauma during birth, stroke, or brain tumors may result in injured brain systems that interfere with sending speech signals to the appropriate muscles. In fact, adults can acquire apraxia as well, in which case the condition is simply called apraxia of speech (AOS).
As with many speech and language disorders, CAS shares symptoms with a variety of other conditions. A skilled speech-language pathologist (SLP) can determine the underlying speech disorder by ruling out similar disorders, like articulation or phonological disorders and dysarthria (muscle weakness). The following symptoms are often seen in children with CAS:
Between 6 months to 2 years. Children’s speech skills typical take off from babbling in the first year to short sentences by the second year. Children with CAS may not be vocalizing or verbalizing at all. Specific markers at these ages include:
Quiet baby with limited cooing and babbling.
Delayed first word, or unusual or missing sounds in the first word.
Very limited repertoire of sounds and spoken words.
Sounds are limited to vowels and consonants if any.
All words may sound the same.
Long pauses between sounds.
May have problems with feeding (chewing, swallowing, gagging).
Between 2 and 4 years. These markers may be observed:
Vowel and consonant distortions, unlike typical articulation disorders.
Separation of syllables in words.
Voicing errors, such as turning on the voice for a voiceless sound (e.g., big instead of pig).
Sounds may be inconsistent, sometimes spot on and sometimes incorrect. This makes it hard for an SLP to determine the pattern of errors. In contrast, children with articulation or phonological disorders typically have a clear pattern of incorrect sounds.
Difficulty imitating sounds or words they have said clearly before.
“Pop out” words. Parents often report that they heard their child say a certain word correctly, but could not get them to repeat it.
Older than 4 years. An older child with CAS may show:
Difficulty producing many speech sounds.
Omitted consonants at the beginning and end of words.
Use of grunts, vowel sounds, or single syllables to communicate.
The need for repeated attempts to pronounce words.
Difficulty moving from one sound, syllable, or word to the next.
Deliberate and forced movements of the jaw, lips, or tongue to make the correct sounds.
An abnormal choppy rhythm of speech. The child may stress the wrong syllable or use pauses at inappropriate times during speech.
Ability to say certain words or sounds sometimes but not other times.
A difficulty with longer sentences and words. The child will opt for shorter alternatives.
Difficulty imitating mouth movements.
Increasingly more unintelligible speech when the child is anxious or nervous.
An understanding of language that is better than he or she can talk.
Other signs that an SLP will look for include:
Co-existing conditions, such as language disorders or muscle weakness.
Difficulty chewing and swallowing.
Symptoms of general apraxia, such as poor fine (writing) or gross (jumping) motor skills.
If CAS is suspected, it is imperative that your child receives a full speech-language evaluation from a qualified speech-language pathologist. At Kidmunicate, our speech-language pathologists will assess the following:
Hearing ability. We suggest that the child have a full evaluation by an audiologist to rule out hearing loss as a possible cause.
Structural problems. All speech areas of the head and neck will be examined, including the lips, tongue, teeth, velum, and jaw, to rule out cleft palate or tongue-tie.
Muscle tone. The articulators (lips, tongue, teeth, velum, and jaw) will be examined to rule out dysarthria (muscle weakness). CAS is a coordination issue, not a strength problem.
Motor coordination. The child’s ability to control the articulators will be assessed by having the child:
Move the tongue from side-to-side and up-and-down.
Move the lips to smile, frown, blow, kiss, or lick.
Motor sequencing. A technique called the diadochokinetic (DDK) rate overview, or the Fletcher Time-by-Count test, will be used to measure how quickly and clearly the child can repeat a series of sounds (or tokens) that contain one, two, or three syllables for example:
/puh puh puh/, or /puh tuh puh tuh/, or /puh tuh kuh puh tuh kuh/
Some common words like pattycake are also used.
Word repetition. Ability to repeat a word multiple times.
Word complexity. Ability to recite short to long words, like power, powerful, powerfully.
Speech prosody. The intonation, melody, or rhythm of the child’s speech. The SLP will listen for appropriate stress on syllables in a word and proper pauses between words and phrases.
Ability to pronounce vowel and consonant sounds.
Language skills. The SLP will also evaluate the child’s receptive language (understanding) and literacy skills (reading).
Childhood apraxia of speech is a complex problem that will require significant speech-language therapy. The treatment of CAS takes time and commitment. ASHA recommends one-on-one therapy sessions with a licensed speech-language pathologist at 3 to 5 sessions per week. We typically recommend 30 minute sessions 3+ times per week. Group therapy is not recommended, especially in the early stages of therapy.
It’s also important to note that as a parent, you will also need to be completely engaged in the process, because extensive home practice is needed to ensure a successful outcome.
Treatment approaches include:
We use multi-sensory feedback to improve muscle coordination and sequencing, which means the child will practice speech using tactile cues that can be felt, seen, and heard (touch, visual, and auditory). This helps the child focus on how the speech movements sound and feel.
Our SLP may use her hands to help the child move his or her lips, such as rounding them to form an “O”.
The child will also touch his or her own face while producing sounds and words.
To encourage increased lip rounding, we may use bubbles, whistles, and apraxia tubes from Talk Tools by Sara Rosenfeld Johnson.
To encourage lip closure, we may also use the apraxia shapes from Talk Tools.
We have also had a lot of success with whole body cues.
We use a mirror so the child can watch the movements of the mouth while saying sounds and words.
Our SLP also demonstrates the speech movements as a model.
The child will listen to a recording of the sounds he or she has made to provide auditory feedback.
Pacing Boards: We love to use simple pacing boards for visual, auditory, touch, and kinesthetic (movement) feedback to reduce the child’s rate of speech, improve sequencing of sounds and syllables in multisyllabic words, and increase the length of phrases or sentences. The child will learn to tap out syllables or words in sentences.
Imitation: The SLP will have the child imitate all vocalizations in their repertoire and selectively reinforce close productions (approximations).
Vowels, Consonants, Syllables, Sound Combinations and Word Production
First, we concentrate on vowel production, which requires less motor coordination than consonant sounds.
We start with a small list of easy sounds (“ooh”), syllables (“boo”), and words (“boot”) and build from there.
We include familiar, functional words used in the child’s everyday life.
We focus on repeated practicing of the movements of the articulators (lips, mouth, teeth, and tongue) to pronounce sounds, syllables, words, and phrases.
Practice improves muscle memory, the ability to recall the oral motor movement.
Rhythms or melodies
We use auditory feedback to practice proper placement of stress and pauses in words and phrases.
Pacing boards are also used for tapping out rhythms.
“Homework”: Speech homework is very important for speech-language disorders.
The child with CAS should practice the speech therapy words and phrases for 10 minutes per day, twice a day, every day.
The child should also practice communication in real life situations.
For example, every time a parent walks into the room, ask the child to say, “Hi Mom” or “Hi Dad”.
Another example, every time you want your child to complete a task, ask your child to say, “Okay, Mom” or “Okay, Dad”.
Alternative communication devices: These devices may help the child with severe apraxia of speech to communicate more effectively, especially in the early stages of therapy. This makes communication less frustrating. We might encourage the use of the following:
Picture Exchange Communication System (PECS): a collection of simple images that depict a variety of verbs, nouns, and adjectives.
There is no magic cure or medicine that will heal childhood apraxia of speech. And it’s not a speech disorder that a child will outgrow. Children with CAS need intensive treatment for a lengthy period of time. The length of therapy is difficult to predict because it varies greatly from child to child depending on the child’s determination, concentration, intelligence, access to therapy, the family’s commitment to practice at home, and co-existing issues (Down Syndrome, Autism, etc.).
There is encouraging news, though! Childhood apraxia of speech can get better. By the age of 8, 9, or 10, your child’s speech can reach the same level as his or her peer group with the occasional hiccup on challenging words or in challenging situations.
“After 8+ years of speech therapy with little improvement, I came to Kidmunicate. My son was finally diagnosed with very mild Childhood Apraxia of Speech. His speech had unique features that made it sound unusual. Pam Drennen worked with my 10-year-old son 3 times per week for 5 months. What she accomplished during that time was amazing! She made the sessions engaging, fun, and not seem at all like therapy—a steep order for someone working with a 10-year-old. My son has not needed any additional therapy since working with Pam.” (Mandy B, Mom of a Kidmunicate Child with CAS).