Childhood apraxia of speech
Childhood apraxia of speech (CAS) is an uncommon speech disorder in which a child has difficulty making accurate movements when speaking.
In CAS, the brain struggles to develop plans for speech movement. With this disorder, the speech muscles aren't weak, but they don't perform normally because the brain has difficulty directing or coordinating the movements.
To speak correctly, your child's brain has to learn how to make plans that tell his or her speech muscles how to move the lips, jaw and tongue in ways that result in accurate sounds and words spoken with normal speed and rhythm.
Children with childhood apraxia of speech (CAS) may have many speech symptoms or characteristics that vary depending on their age and the severity of their speech problems.
CAS can be associated with delayed onset of first words, a limited number of spoken words, or the ability to form only a few consonant or vowel sounds. These symptoms usually may be noticed between ages 18 months and 2 years, and may indicate suspected CAS.
As children produce more speech, usually between ages 2 and 4, characteristics that likely indicate CAS include vowel and consonant distortions; separation of syllables in or between words; and voicing errors, such as "pie" sounding like "bye."
Many children with CAS have difficulty getting their jaws, lips and tongues to the correct position to make a sound, and they may have difficulty moving smoothly to the next sound.
Many children with CAS also have language problems, such as reduced vocabulary or difficulty with word order.
Some symptoms may primarily be seen in children with CAS and can be helpful to diagnose the problem.
However, some symptoms of CAS are also symptoms of other types of speech or language disorders. It's difficult to diagnose CAS if a child has only symptoms that are found in both CAS and in other types of speech or language disorders.
Some characteristics, sometimes called markers, help distinguish CAS from other types of speech disorders. Those particularly associated with CAS include:
- Difficulty moving smoothly from one sound, syllable or word to another
- Groping movements with the jaw, lips or tongue to make the correct movement for speech sounds
- Vowel distortions, such as attempting to use the correct vowel, but saying it incorrectly
- Using the wrong stress in a word, such as pronouncing "banana" as "BUH-nan-uh" instead of "buh-NAN-uh"
- Using equal emphasis on all syllables, such as saying "BUH-NAN-UH"
- Separation of syllables, such as putting a pause or gap between syllables
- Inconsistency, such as making different errors when trying to say the same word a second time
- Difficulty imitating simple words
- Inconsistent voicing errors, such as saying "down" instead of "town," or "zoo" instead of "Sue"
Other characteristics are seen in most children with speech or language problems and aren't helpful in distinguishing CAS. Characteristics seen in both children with CAS and in children with other types of speech or language disorders include:
- Reduced amount of babbling or vocal sounds from ages 7 to 12 months old
- Speaking first words late (after ages 12 to 18 months old)
- Using a limited number of consonants and vowels
- Frequently leaving out (omitting) sounds
- Difficult to understand speech
Other speech disorders sometimes confused with CAS
Some speech sound disorders often get confused with CAS because some of the characteristics may overlap. These speech sound disorders include articulation disorders, phonologic disorders and dysarthria.
A child who has trouble learning how to make specific sounds, but doesn't have trouble planning or coordinating the movements to speak, may have an articulation or phonologic disorder. Articulation and phonologic disorders are more common than CAS.
Articulation or phonologic speech errors may include:
- Substituting sounds, such as saying "fum" instead of "thumb," "wabbit" instead of "rabbit" or "tup" instead of "cup"
- Leaving out (omitting) final consonants, such as saying "duh" instead of "duck" or "uh" instead of "up"
- Stopping the airstream, such as saying "tun" instead of "sun" or "doo" instead of "zoo"
- Simplifying sound combinations, such as saying "ting" instead of "string" or "fog" instead of "frog"
Dysarthria is a motor speech disorder that is due to weakness, spasticity or inability to control the speech muscles. Making speech sounds is difficult because the speech muscles can't move as far, as quickly or as strongly as normal. People with dysarthria may also have a hoarse, soft or even strained voice, or slurred or slow speech.
Dysarthria is often easier to identify than CAS. However, when dysarthria is caused by damage to certain areas of the brain that affect coordination, it can be difficult to determine the differences between CAS and dysarthria.
Childhood apraxia of speech (CAS) has a number of possible causes, but in many cases a cause can't be determined. Doctors often don't observe a problem in the brain of a child with CAS.
CAS may be the result of brain (neurological) conditions or injury, such as a stroke, infections or traumatic brain injury.
CAS may also occur as a symptom of a genetic disorder, syndrome or metabolic condition. For example, CAS occurs more frequently in children with galactosemia.
CAS is sometimes referred to as developmental apraxia. However, children with CAS don't necessarily grow out of CAS as they develop. In many children with delayed speech or developmental disorders, children follow usual patterns in development of speech and sounds, but they develop more slowly than usual.
Children with CAS don't make typical developmental sound errors. They need speech therapy to make maximum progress.
Abnormalities in the FOXP2 gene appear to increase the risk of childhood apraxia of speech (CAS) and other speech and language disorders. The FOXP2 gene may be involved in how certain nerves and pathways in the brain develop.
Researchers continue to study how abnormalities in the FOXP2 gene may affect motor coordination and speech and language processing in the brain.
Many children with childhood apraxia of speech (CAS) have other problems that affect their ability to communicate. These problems aren't due to CAS, but they may be seen along with CAS.
Symptoms or problems that are often present along with CAS include:
- Delayed language, such as difficulty understanding speech, reduced vocabulary, or difficulty using correct grammar when putting words together in a phrase or sentence
- Delays in intellectual and motor development and problems with reading, spelling and writing
- Difficulties with gross and fine motor movement skills or coordination
- Hypersensitivity, in which the child may not like some textures in clothing or the texture of certain foods, or the child may not like tooth brushing
Diagnosing and treating childhood apraxia of speech at an early stage may reduce the risk of long-term persistence of the problem. If your child experiences speech problems, it's a good idea to have a speech-language pathologist evaluate your child as soon as you notice any speech problems.
To evaluate your child's condition, your child's speech-language pathologist will review your child's symptoms and medical history, conduct an examination of the muscles used for speech, and examine how your child produces speech sounds, words and phrases.
Your child's speech-language pathologist will also assess your child's language skills, such as his or her vocabulary, sentence structure and ability to understand speech.
Diagnosis of CAS isn't based on any single test or observation. It depends on the pattern of problems that are seen. The specific tests conducted during the evaluation will depend on your child's age, ability to cooperate and the severity of the speech problem.
It can sometimes be difficult to diagnose CAS, especially when a child speaks very little or has difficulty interacting with the speech-language pathologist.
It's important to identify whether your child shows symptoms of CAS, because CAS is treated differently from other speech disorders. Your child's speech-language pathologist often may be able to determine an appropriate treatment approach for your child, even if the diagnosis is initially uncertain.
Tests may include:
- Hearing tests. Your doctor may order hearing tests to determine if hearing problems could be contributing to your child's speech problems.
Oral-motor assessment. Your child's speech-language pathologist will examine your child's lips, tongue, jaw and palate for structural problems, such as tongue-tie or a cleft palate, or other problems, such as low muscle tone. Low muscle tone usually isn't associated with CAS, but it may be a sign of other conditions.
Your child's speech-language pathologist will observe how your child moves his or her lips, tongue and jaw in activities such as blowing, smiling, and kissing.
Speech evaluation. Your child's ability to say sounds, words and sentences will be observed during play or other activities.
Your child may be asked to name pictures to see if he or she has difficulty making specific sounds or speaking certain words or syllables.
Your child's speech-language pathologist may evaluate your child's coordination and smoothness of movement in speech during speech tasks. To evaluate your child's coordination of movement in speech, your child may be asked to repeat syllables such as "pa-ta-ka" or say words such as "buttercup."
If your child can produce sentences, your child's speech-language pathologist will observe your child's melody and rhythm of speech, such as how he or she stresses syllables and words.
Your child's speech-language pathologist may help your child be more accurate by providing cues, such as saying the word or sound more slowly or providing touch cues to his or her face.
Speech-language pathologists may treat childhood apraxia of speech (CAS) with many therapies.
Your child's speech-language pathologist will usually provide therapy that focuses on practicing syllables, words and phrases. When CAS is relatively severe, your child may need frequent speech therapy, three to five times a week. As your child improves, the frequency of speech therapy may be reduced.
Children with CAS generally benefit from individual therapy. Individual therapy allows your child to have more time to practice speech during each session.
It's important that children with CAS get a significant amount of practice saying words and phrases during each speech therapy session. Learning to say words or phrases takes children with CAS time and practice.
Because children with CAS have difficulties planning movements for speech, speech therapy often focuses your child's attention to the sound and feel of speech movements.
Speech-language pathologists may use different types of cues in speech therapy. For example, your child's speech-language pathologist may ask your child to listen carefully and watch him or her form the target word or phrase with his or her mouth.
Your child's speech-language pathologist also may touch your child's face as he or she makes certain sounds or syllables. For example, your child's speech-language pathologist may use his or her hands to help your child round his or her lips to say "oo."
No single speech therapy approach has been shown to be most effective for treating CAS, but some important general principles of speech therapy for CAS include:
- Your child's speech-language therapist will focus on speech drills, such as asking your child to say words or phrases many times during a therapy session.
- Your child will be asked to listen to the speech-language pathologist and to watch his or her mouth as he or she says the target word or phrase. By watching the speech-language pathologist's mouth, your child also sees the movements that go along with the sounds.
- Your child will most likely practice syllables, words or phrases, rather than isolated sounds, during speech therapy. Children with CAS need practice making the movements from one sound to another.
- Because many children with CAS distort vowel sounds, your child's speech-language pathologist may choose words for your child to practice that contain vowels in different types of syllables. For example, your child may be asked to say "hi," "mine" and "bite," or "out," "down" and "house."
- If your child has severe CAS, your child's speech-language pathologist may use a small set of practice words at first, and gradually increase the number of words for practice as your child improves.
Speech practice at home
Because speech practice is very important, your child's speech-language pathologist may encourage you to be involved in your child's speech practice at home.
Your child's speech-language pathologist may give you words and phrases to practice with your child at home that he or she has learned in speech therapy. Each home practice session can be short, such as five minutes in length, and you may practice with your child twice a day.
Children also need to practice words and phrases in real-life situations. Create situations where it will be appropriate for your child to say the word or phrase spontaneously. For example, ask your child to say "Hi, Mom" each time mom enters a room. Practicing words or phrases in real-life situations will make it easier for your child to say the practice words automatically.
Alternative communication methods
If your child has a severe speech disorder and can't effectively communicate, alternative communication methods can be very helpful.
Alternative communication methods may include sign language or natural gestures, such as pointing or pretending to eat or drink. For example, your child could use signs to communicate he or she wants a cookie. Sometimes electronic devices, such as electronic tablets, can be helpful in communication.
It's often important to use alternative communication methods early. Using these methods may help your child become less frustrated when trying to communicate. It may also help your child to develop language skills such as vocabulary and the ability to put words together in sentences.
As speech improves, these strategies and devices may no longer be necessary.
Therapies for coexisting problems
Many children with CAS also have delays in their language development, and they may need therapy to address their language difficulties.
Children with CAS who have fine and gross motor movement difficulties in their arms or legs may need physical or occupational therapy.
If a child with CAS has another medical condition, then effective treatment for that condition may be important to improving the child's speech.
Treatments that aren't helpful for CAS
Some treatments aren't helpful in improving the speech of children with CAS. For example, there is no evidence to show that exercises to strengthen speech muscles will help improve speech in children with CAS.
Lifestyle and home remedies
You and your family can work with your child at home to improve his or her speech and language skills. Home practice, in addition to your child's speech therapy sessions, may help your child's progress.
Encourage and support your child as he or she practices speech and language skills. Your support can help your child feel that he or she is doing well and improving.
If your child is participating in physical or occupational therapy, as well as speech therapy, schedule different types of therapy at various times so that your child doesn't become too tired from therapy.
Coping and support
It can be difficult to have a child who has problems communicating. There are a number of support groups available for parents of children with childhood apraxia of speech. Support groups may offer a place for you to find people who understand your situation and who can share similar experiences.
To learn about support groups in your area, see the Apraxia-KIDS website.
Preparing for your appointment
Your child is likely to start by seeing a doctor trained in the general care and treatment of children (pediatrician) or a doctor trained in treating children with neurological conditions (pediatric neurologist). Your child will then be referred to a specialist in speech and language conditions (speech-language pathologist).
Because appointments have limited time, and because there's often a lot to talk about, it's a good idea to be well-prepared for your child's appointment. Here's some information to help you and your child get ready, and what to expect from your child's doctor and speech-language pathologist.
What you can do
- Write down any symptoms your child is experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Bring a list of all medications, vitamins or supplements that your child is taking.
- Write down questions to ask your child's doctor and speech-language pathologist.
- Bring a copy of a recent progress report and individual education plan from your child's speech-language pathologist if your child has previously been seen by a speech-language pathologist.
Your time with your child's doctor or speech-language pathologist is limited, so preparing a list of questions ahead of time will help you make the most of your time together. For childhood apraxia of speech (CAS), some basic questions to ask the speech-language pathologist include:
- Does my child have CAS, or any other speech or language problems?
- What is CAS?
- How is CAS different from other types of speech disorders?
- Is my child's condition going to improve?
- What treatments are available, and which do you recommend?
- What can I do at home to help my child?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend?
In addition to the questions that you've prepared to ask your child's doctor or speech-language pathologist, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your child's speech-language pathologist
Your child's speech-language pathologist is likely to ask you a number of questions. Being ready to answer them may allow more time to ask questions about your child's diagnosis and recommended treatment. Your child's speech-language pathologist may ask:
- When did you first have concerns about your child's speech development?
- Did your child babble? For example, did your child produce cooing sounds and then produce syllables, such as "ba-ba-ba" or "da-da-da"? If so, when did that start?
- When did your child say his or her first word?
- When did your child have five words in his or her vocabulary that he or she would use frequently?
- How many words does your child currently have in his or her vocabulary that would be understandable to most people?
- In what other ways does your child communicate? For example, does your child point, make gestures, make signs or act things out?
- Has anyone in your family had speech or language difficulties?
- Has your child had ear infections? About how many ear infections has he or she had?
- When was your child's hearing tested? Was any hearing loss detected?
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