Childhood Apraxia of Speech (CAS) is a motor speech disorder that significantly impacts a child’s ability to communicate. Today I am going to share with you the ins-and-outs of this somewhat controversial speech disorder.
What are motor speech disorders?
Motor speech disorders are a group of speech disorders characterized by difficulty with the motor aspect of speech. They can involve difficulty with the coordination and planning of movements needed for speech or difficulties with the strength of the articulatory and respiratory system.
What is Childhood Apraxia of Speech?
Childhood Apraxia of Speech, or CAS, is a motor speech disorder. Children with CAS have difficulty producing sounds, syllables and words. For reasons unknown, the brain has difficulty with planning and executing the fine motor movements needed for speech. The child knows what he wants to say, but the brain is having difficulty coordinating or “talking to” if you will, the parts of the parts of the body that are used to produce speech sounds (i.e. the vocal folds, lips, jaw, tongue and palate). Basically the part of the brain that is responsible for controlling the parts of the body responsible for speech production is either not fully developed or damaged. CAS is NOT due to muscle weakness or paralysis (which is seen in another motor speech disorder, dyarthria) and the child should have no issues with spontaneous non speech movements like coughing, laughing, chewing or swallowing.
What are other names for CAS?
Over the years there have been many terms used to describe this disorder and if go Googling you may see them. Some of these terms include: dyspraxia, apraxia, apraxia of speech, developmental apraxia of speech (DAS), suspected childhood apraxia of speech (sCAS), developmental verbal dyspraxia (DVD) or developmental articulatory dyspraxia (DAD) ( http://speech-language-therapy.com/phonol-and-artic.htm ) Why so many names? According to Caroline Bowen, PhD and speech-language pathologist (at the link above), one reason for the different names is a result of the different theories of the underlying cause of CAS.
What causes childhood apraxia of speech?
We simply do not know what causes CAS. Some possible causes may include genetic disorders or syndromes, strokes, or other brain injury. But most of the time, the cause is unknown.
What are the signs and symptoms of childhood apraxia of speech?
This is where it gets complicated and believe it or not, controversial. First of all, no two children with CAS present the same.Second, (and this is a big issue) there is no agreed upon set of criteria for diagnosing CAS. And third, many of the “possible signs” will also be seen in a child without CAS that may have a speech or language delay, or another disorder.
Some Key Signs of CAS
- Inconsistent vowel and consonant errors
- Difficulty in sequencing speech sounds/phonemes ans may have breaks between sounds
- Difficulty producing longer words vs shorter ones
- Speech sounds choppy, monotonous, or stress is on the wrong syllable or word
- Significant difficulty imitating speech (but imitated speech is more clear than spontaneous speech)
- Difficulties regulating rate, nasality, loudness, pitch
Characteristics that a child with CAS may display that are common in children with other speech/language delays
- Little or no cooing or babbling as an infant
- Delay in first words
- Limited verbal output
- Child can understand more than he/she can say
- Is very hard to understand, especially for an unfamiliar listener
- May use gestures or signs to communicate more than with words
- Using only a few different speech sounds (tend to be “early” sounds like b,p,m,d)
- May appear to be groping while trying to produce speech
Some possible associated problems
- Delay in language, language disorders
- Gross or fine motor skill deficits (problems in coordination or problems with handwriting or typing)
- Other learning disabilities (issues with learning how to read, write, and spell)
- In some cases, hearing impairment, neuromuscular disorders, other syndromes or mental retardation.
How is Childhood Apraxia of Speech Diagnosed?
CAS is diagnosed after a very thorough assessment by a speech-language pathologist. The first step in the assessment process is typically a hearing test by an audiologist to rule out any hearing loss as a possible cause of the symptoms. During the assessment process, the SLP will:
- Spend a great deal of time interviewing parents and caregivers regarding their concerns
- Take a very thorough developmental history of the child
- Observe the child playing and interacting with caregivers
- Perform an oral-motor skill exam (looking for signs of weakness of the oral structures and articulators; examine how well the child can coordinate non-speech movement in the oral structure such as moving the tongue back and forth, smiling, frowning, puckering lips); evaluate how the child coordinates and sequences motor movements for speech; and examining the child’s ability to perform automatic and non automatic movements-like licking a real sucker and licking a “fake” sucker).
- Perform a speech sound assessment to determine what speech sounds the child can and cannot make (individual consonants, vowels, consonant blends, sounds in words, sounds in phrases) and determine how intelligible the child’s speech is to others.
- Take a speech sample to analyze for the type of errors, consistency of errors, intelligibility, rate of speech, and prosody.
- Formally or informally evaluate the child’s voice and respiration
- Perform either a formal or informal assessment of the child’s receptive and expressive language skills
What is the treatment for Childhood Apraxia of Speech?
Treatment for CAS involves frequent and intensive speech therapy. Research has shown that children with CAS do best with individual therapy (as opposed to group) 3+ times a week, usually in 30-45 minute sessions when first diagnosed. As the child improves therapy may not be needed as often and group therapy may then be appropriate.
Intervention for CAS focuses on planning, sequencing and coordinating the muscle movements needed for speech. Each individual SLP’s therapy with each individual child may look different, as no two children are alike (the same goes for any type of speech therapy). Using a multi-sensory approach is often helpful for children with CAS (i.e. using tactile feedback like touching inside the mouth where the tongue needs to go to make a sound, auditory feedback like telling them where to put their articulators, and visual feedback like having the child watch himself in the mirror).
An important note regarding speech therapy for CAS: It does NOT include exercises to “strengthen” the muscles for articulation, as CAS is NOT a disorder of weakness. It is a disorder of muscle coordination.
For some children, the use of an alternative or augmentative form of communication may be recommended in conjunction with intensive speech therapy. This could include using sign language, a picture communication system, or an augmentative device (similar to a computer that can write or produce speech). A child who cannot communicate is often very frustrated, and this frustration can (and often does) result in unwanted behaviors like severe tantrums. This is because they cannot communicate. Communication and speech are not the same: speech is just one mode of communication. Giving them an alternative way to communicate typically will reduce the incidence of unwanted behaviors due to the inability to communicate (like tantrums). Then the child may be more readily able to participate in his intensive speech therapy sessions. The use of an alternative system will NOT delay the child’s speech further, and the child will NOT just give up on trying to talk once they have the alternative system in place.
Another important aspect of treatment is home practice. Once the SLP gives the OK, home practice is VERY IMPORTANT (this is true of any speech therapy interventions). More practice=faster progress.
Where can I get more information on Childhood Apraxia of Speech?
I HIGHLY recommend the book (affiliate link ->) Speaking of Apraxia: A Parents’ Guide to Childhood Apraxia of Speech if you suspect your child has CAS.
The American Speech-Language Hearing Association has some information HERE
Caroline Bowen, PhD SLP’s website has info HERE
The Childhood Apraxia of Speech Association of North America (CASANA) has a plethora of information HERE
American Speech-Language Hearing Association Website (2011). Childhood Apraxia of Speech. Retrieved from http://www.asha.org/public/speech/disorders/childhoodapraxia.htm (9-27-2011)
Bowen, Caroline, (1998). Children’s Speech Sound Disorders: Questions and Answers. Retrieved from http://speech-language-therapy.com/phonol-and-artic.htm (9-27-2011).
Hegde, M.N., (2001). Pocket Guide to Assessment in Speech-Language Pathology (2nd edition). San Diego, CA: Singular Publishing Group.
Hodge, Megan M., (2008). Motor speech disorders in pediatric practice [PDF]. ASHA Conference: Chicago, IL. Retrieved from http://search.asha.org/default.aspx?q=Motor%20speech%20disorders.