What is Childhood Apraxia of the Speech (CAS) and how is it treated?
Katie Dimond M.A. CCC-SLP and Son Miles
Katie Dimond, a certified Speech Language Pathologist, is PROMPT (PROMPTS for Restructuring Oral Muscular Phonetic Targets) trained, has completed the Advanced Training Workshop for Childhood Apraxia of Speech, and is a clinical researcher for the Once Upon A Time Foundation and Practice Team at the Marquette CML Lab. She can be found on the Apraxia Kids website as a provider for childhood apraxia of speech.
My Personal Experience:
I am a speech and language pathologist and a mother of three. When my youngest son, Miles, wasn’t meeting speech milestones I started to explore contributing factors. It turns out he had childhood apraxia of speech! This topic hits close to home as a mom and a speech therapist, and I wanted to share our journey with you.
Many of you probably have not heard of Childhood Apraxia of Speech (CAS) or of motor speech disorders in general. Don’t worry, you are not alone. Hopefully this article will provide somebasic background for you. Who knows, maybe your child has the same difficulties, or you know someone who does.
Miles said his first word around 8-months, “dada”. We had a feral cat in our neighborhood who lived under the couch on our porch last winter. My kids would get so excited when they saw the cat. Miles was about 12-months when he said “cat” a few times. My heart skipped a beat when I heard him say that word, clear as day. He was on track to be an early talker just like his older brother. Unfortunately, I never heard him say cat again. Cat was a “pop out word.” Children with apraxia often can say words spontaneously––the words just pop out. But then they don’t seem able to say these words again on demand.
He babbled a lot as a baby, mostly producing the sound ‘ba.’ Everything was “ba.” He made many approximations towards words and at about 18-months he had about ten words: dada, more, uh oh (produced like “uh uh”), dog (produced like “da”), duck (produced like “da”), book (produced like “ba”), bunny (produced like “ba”), no (produced like “na”), yay (produced like “ya”.) This wasn’t so bad, at least he had some words, right? But in my gut, I felt like something was not right with his speech.
Miles was an early crawler (7 months) and walker (10 months). He had great play, problem-solving, and learning skills. My older son was speaking full sentences by the time he was 18-
months old. I couldn’t imagine Miles would be delayed in anything, especially talking, as I am a speech therapist for goodness’ sake!
I talked to his pediatrician, and she said he was “fine” and there was no need for speech therapy to get involved. She sees kids with speech delays all the time and, to her, he was not delayed. I was thinking, I see kids with speech delays all the time too and something is not adding up.
I consulted with another speech therapist and she started seeing Miles. We both thought he may have motor planning difficulties and maybe apraxia.
When he turned 20 months and was still not showing any improvement I got incredibly nervous and decided it was time to form a plan. I began to get more concerned about apraxia. Back then, I had knowledge of CAS, but hadn’t had the opportunity to attend specialized training in therapy approaches and treatment. I started googling and that scared me even more. A million thoughts flowed through my head.
The plan I formed helped me. If I could do everything in my power for my child to get better and make progress, then I was doing all I could as his mom. I decided, after doing more research, he needed speech therapy at least 3-times a week and got him signed up
immediately. His therapist also recommended he receive occupational therapy. Occupational
therapy assisted with his ability to pay attention and focus as well as on his body regulation.
My plan worked. Miles received occupational therapy once a week until he was 4 years old and speech therapy three times a week until he was 5 years old. Miles graduated from speech therapy in the summer of 2022. I am thankful for his therapists. I am thankful I did not listen to his pediatrician and follow the “wait and see” approach that is unfortunately often suggested. Trust your gut parents, it’s usually right.
Childhood Apraxia of Speech (CAS) Explained:
CAS is a label for a type of speech sound disorder, not a medical diagnosis.
Childhood Apraxia of Speech (CAS) is considered a neurological speech disorder that affects a child’s ability to clearly and correctly produce syllables and words. The most obvious thing that others notice is that the child has significantly limited and/or unclear speech. (Apraxia-kids.org)
CAS reflects an impairment of speech motor programming and planning, which is evidenced by difficulties moving from one speech sound to the next, inconsistent errors on vowels and consonants, and prosodic problems (ASHA, 2007; Grogos & Kolenda, 2010; Nijland et al,. 2002; Skinder, Strand, & Mignerey, 1999; Terband, Maassen, van Lieshout, and Nijland, 2011.) In addition, it has been suggested that children with CAS also have difficulties with speech motor learning, based on their often noted slow, limited progress in treatment (e.g., Ballard, Robin, McCabe, & McDonald, 2010; Cambell, 1999; Srhiberg, Aram, & Kwaikowski, 1997; Strand, Stoeckel, & Bass, 2006.)
Speaking is complex! Here is what happens when you speak: Messages need to go from your brain to your mouth. These messages tell the muscles how and when to move to make sounds. If your child has apraxia of speech, the messages do not get through correctly. Your child might not be able to move their lips or tongue to the right place to say sounds, even though their muscles are not weak. Sometimes, they might not be able to say much at all. In CAS, there is an inefficiency of neuro impulses that plan and program movement for speech production. There is a lot of sensory information and proprioceptive information that lets the part of the brain know what is moving and what is still, and this helps to tell the muscles how to contract and how many muscles should contract and at what time.
Children with CAS know what they want to say, but the brain is not able to make the mouth muscles move in the patterns they need to in order to produce speech. (www.asha.org)
My child has good language, comprehension skills, and good attention, could they have CAS?
Yes, yes, they can. Many children with CAS possess appropriate receptive skills and comprehension skills, they just may not be able to get their words out, or maybe they are verbal but still displaying characteristics of CAS. Many children who have been in speech therapy for a considerable amount of time with limited or no progress, may possess relatively good language comprehension and attention skills, and may have CAS. Many of these children have difficulty in sensorimotor planning and programming speech movements and have not responded to traditional methods of treatment for phonology and articulation (Strand, Stoeckel, & Bass, 2006.)
Children who have been in speech therapy for a long time, who present with severe speech sound disorders (SSDs) and who are minimally verbal, non-verbal, or barely intelligible to an outside listener, will benefit from working with a speech therapist with special training in the area of CAS and motor planning for speech production. Dynamic Temporal and Tactile Cueing (DTTC) was designed specifically for severe SSD, especially CAS, and provides clinicians a clear understanding of the theory and principles that contributed to the design of the treatment and to clinical decisions that must be made when implementing DTTC. Examples include: frequent services, specific targets, and repetitive practice.
Symptoms of Childhood Apraxia of Speech:
2-year-old children and younger:
- Lack of a consonant sound by 12-months old.
The early consonant sounds are: “p,” “b,” “m,” “n,” “d,” “t,” “w,” “h.” - Limited vocalizations in the first 2 years of life. Your child may be described as quiet and doesn't babble or speak much.
- Limited syllable shapes: they speak in mostly one syllable words and reduce words down to one syllable (examples: “ma” means mom, milk, more.)
- Use fewer than 5 consonants by 24-months-old
- Use of fewer than 3 consonants by 16-months-old.
- Lack of posterior sounds by 24-months-old: Inability to produce 'k' and 'g' sounds.
- Preference of stop and nasal sounds by 24-months-old: They can produce words with stop sounds “p,” “b,” “d,” “t,” and nasal sounds “m”, “n”, “ng” while missing other consonant sounds.
3 -year-old children and younger:
- Inconsistency speech sound errors.
- Pauses between sounds and or syllables; difficulty blending sounds in words together.
- Difficulty with prosody; intonation, rate, rhythm, stress, and voice quality challenges.
- Voicing errors. Errors in voicing, such as a voiceless sound replaced by a voiced sound (e.g., dop instead of top.)
- Visible effort to communicate using speech.
- Vowel errors. Many children with CAS neutralize vowels. (e.g., ba instead of bye or hot instead of hat.)
- The longer the word the more difficult it is for them. Sounds or syllables may be left out or replaced with others that are easier for the child to produce.
- Reversing sounds or syllables in words.
What Causes Childhood Apraxia of Speech (CAS)?
Genetic causes – Around a third of children will have a genetic basis for CAS. Genetic testing is available to rule out genetic factors.
Neurological impairment may be caused by infection, illness, seizures or injury, before, during or after birth.
Idiopathic speech disorder (a disorder of “unknown” origin). Most children with apraxia have an idiopathic cause.
Who can diagnose Childhood Apraxia of Speech?
A speech therapist who is experienced in treating and diagnosing childhood apraxia of speech should diagnose it. A label cannot just be given without dynamic assessment. Dynamic assessment involves a process in which cueing is supplied to facilitate performance and thus disclose emerging skills. Incorporation of dynamic assessment as part of motor speech skill testing would allow observation of what the child does when he or she attempts movement gestures for specific syllable shapes (versus what he or she does habitually, as in a spontaneous speech sample.) Dynamic assessment uses a test, teach, and retest model.
To participate in the formal standardized evaluation, the child needs to be able to try and verbally imitate words. If a child is unable to produce speech or imitate speech, they may display other characteristics of CAS that would lead a clinician to suspect they have it. This may mean the speech pathologist needs to work with the child for a while before they receive a full evaluation that includes a standardized assessment to diagnose apraxia. When a speech therapist evaluates a child and the child is unable to imitate but is displaying characteristics that align with CAS they may say, your child has suspected childhood apraxia of speech (SCAS.) After having speech therapy for a period of time, they may end up having CAS or maybe they will not.
A CAS evaluation can include an articulation assessment, a language sample or evaluation, a phonetic and phonemic inventory, an oral structure function exam, a non-verbal oral apraxia examination, and the Dynamic Evaluation of Motor Speech Skills (DEMSS.) The DEMSS is a dynamic assessment. A thorough dynamic assessment can diagnose apraxia. Each therapist may perform their evaluations a bit differently.
What helps children with Childhood Apraxia of Speech?
CAS and suspected CAS (SCAS) is not a problem that children outgrow. A child with a developmental speech disorder learns sounds in a typical order, just at a slower pace. If your child has CAS, they will not follow typical patterns and will not make progress without treatment. It will take a lot of work, but your child’s speech can improve with the proper treatment approach.
Frequent and intense speech therapy sessions by an experienced SLP is recommended for the best outcome. With appropriate dosage (at least three to four times per week), children will progress to the point where the methods used in DTTC are not needed (often less than a year), and the clinician will move to other methods for treating severe speech sound disorders (SSD) including more linguistically based treatment.
Speech therapy for children with CAS is focused on providing the child with a significant number of opportunities to practice planning, programming and then producing accurate movements for speech. Speech therapy should focus on movements instead of sounds.
If a child has suspected childhood apraxia of speech a motor speech approach to treatment should be taken. This may include blocked practice, mass practice, and using DTTC in treatment. Blocked practice is practicing the same skill under the same conditions, and this can lead to more rapid gains in performance. Random practice means adding variability which can improve retention and transfer. Massed practice involves practicing a target many times during a single session.
The speech therapist you choose to work with your child with CAS should have special training in this area, outside of what was provided in graduate school. The clinician should be knowledgeable about the principles of motor learning and how application of those principles is integral to treatment planning. There should be rationale for each clinical decision made.
What is DTTC?
Dr. Edythe Strand PHD. designed Dynamic Temporal and Tactile Cueing (DTTC) to treat CAS. To be a candidate for DTTC the person must be able to focus attention on the clinician’s face for at least a few minutes at a time and be able to attempt direct imitation. This treatment emphasizes the shaping of movement gestures for speech production and the continued practice of those gestures, in the context of speech. This method uses a specific hierarchy of temporal delay. DTTC allows opportunity for the child to take increasing responsibility for assembling, retrieving, and executing motor plans with progressively less cueing or help.
The goal of DTTC is to improve the efficiency of neural processing for the development and refinement of sensorimotor planning and programming. Important clinical decisions regarding stimuli, organization of practice, and feedback are based on principles of motor learning to facilitate acquisition, retention, and continued improvement of motor speech skills.
The Takeaway:
I hope you have a better understanding of CAS. It is a complex topic and difficult to fully understand. If you think your child may have CAS I urge you to find a speech therapist that can help your child, one that is the right fit for you, one with specialized training. Do not wait and see, do not waste the months or years. Trust your gut, form a plan, and get moving.
I am very devoted to helping children who have CAS and SCAS. I enjoy treating these children and helping them progress. Talking to their families and watching their faces and seeing their emotions as their children begin to talk is extremely rewarding. One of the reasons I feel fulfilled in my work and in my life is because I can help.
References:
1. What you Should Know. 2018. Apraxia Kids. www.apraxia-kids.org
content/uploads/2015/05/What-You-Should-Know.pdf
2. Childhood Apraxia of Speech. American Speech-Language-Hearing Association.
https://www.asha.org/public/speech/disorders/childhood-apraxia-of-speech/
3. BY PROFESSOR ANGELA MORGAN Ph.D., BSpPath (Aud Hons), and MARIANA LAURETTA
MSpPath, Biomed, MURDOCH CHILDREN’S RESEARCH INSTITUTE & UNIVERSITY OF MELBOURNE, MELBOURNE, AUSTRALIA with ORIGINAL CONTRIBUTIONS BY HEIDI FELDMAN, M.D., Ph.D. Reference: Overby, Caspari, & Schreiber (2019). Volubility, Consonant Emergence, and Syllabic Structure in Infants Later Diagnosed with CAS, Speech Sound Disorder, and Typical Development. Journal of Speech, Language and Hearing Research, 62(6), 1657-1675.
4. Maas, Edwin. Butalla, Chistine. Farinella, Kimberly. Feedback Frequency in Treatment for Childhood Apraxia of Speech. American Journal of Speech-Language-Pathology. Vol.2 239-257. August 2012. American Speech-Language-Hearing Association.
5. Strand, Edythe A. Dynamic Temporal and Tactile Cueing: A Treatment Strategy for Childhood Apraxia of Speech. American Journal of Speech-Language Pathology. Vol 29. 30-48. February 2020. American Speech-Language-Hearing Association. Copyright 2019.
