Childhood Apraxia of Speech (CAS) falls under the umbrella term “speech sound disorders.” Children with speech sound disorders have difficulty with motor production, perception, and/or phonological representation of sounds. Stress and prosody (speech intonation patterns) are also included in this definition. Childhood Apraxia of Speech (CAS) occurs in about 15% of three-year old children. The hallmark of CAS is inefficient speech praxis abilities, the ability to volitionally plan and program complex, sequenced muscular motor movements required for speech sound production (Campbell et al. 2003). By age 6, approximately 3.8% of children with CAS will continue to have impaired speech production skills (Shriberg et al. 1999).
Children with CAS often demonstrate limited consonant and vowel repertoire, use of simple syllable shapes, poor intelligibility, vowel distortions, prosodic errors (characterized by equal stress and/or segmentation), and difficulty moving from one articulatory configuration (word) to the next.
CAS can be hard to diagnose in children that cannot yet imitate clinician speech prompts. The speech of children with severe articulation deficits or phonological impairments can appear similar to the speech of children with CAS. However, it should be noted that children with articulation deficits or phonological impairments typically have good prosody and rate of speech.
The following excerpt describes a child I treated with CAS:
What I remember most about *Ryan’s speech sessions was the silence. When Ryan and I played with toys in the therapy room, no audible sound effects were heard. He did not babble; he did not ask questions; he did not ask for help; he did not relay information. The room was as silent as a first snow. Ryan was 5 years old.
Ryan had chocolate-brown hair perpetually slicked back by his mother, reminiscent of a 1950’s style. His twinkling, almond eyes matched his hair, and were often squinched up from his jovial smile. Although he could only articulate three consonant-vowel combinations: ma, no, and da, he was the happiest child I had ever treated. His mother had taught him an extensive number of ASL signs (American Sign Language); however, he often had difficulty recalling them, especially when put on the spot (which mother’s often do – myself included). His main mode of communication was miming accompanied by vocalizations.
His diagnosis… a severe motor speech disorder with possible Childhood Apraxia of Speech (CAS).
Ryan was cognitively bright and socially appropriate. He knew he could not speak, so he remained quiet. With intense modeling and tactical prompting, he could imitate about 5 consonants (t,p,w,b,g). His vowels were almost always distorted. His family wanted him to play for the Oregon Ducks. They shared this goal with me upon my suggestion of trialing a dynamic-display, augmentative communication device (AAC) for him to better communicate. This is a device that looks like an iPad that allows children to press buttons to speak for them. Ryan’s parents told me they did not want him using a “talker”…EVER. Looking me deep in the eyes, his father whispered under his breath, “Football players don’t use talkers.”
So, you may be wondering why the parents were unnerved by the implementation of an AAC device. Fortunately, this was no surprise to me. As a speech therapist for over ten years, I know firsthand that AAC implementation can often be a difficult topic with parents. Before I explain that issue, I wish to discuss oral communication skills versus expressive language skills. This way, you can better understand how AAC can profoundly impact children severely effected by motor speech deficits in a positive way.
SLP’s divide oral communication into two arenas: speech and language.
1.) Speech Production (or) Motor Speech – getting articulators (lips, tongue, velum, teeth, palate, pharynx) to the right place at the right time with adequate strength to make the sounds of speech
2.) Expressive Language – organizing thoughts and ideas into coherent sentences using accurate grammar and age appropriate vocabulary
If a child has very poor speech production skills, it causes his expressive language skills to be delayed as well. This communicative delay in the presence of age appropriate cognition (thinking and understanding skills) often frustrates children because they cannot get their wants and needs met or their thoughts and ideas conveyed effectively and efficiently. Their motor speech skills do not match their language abilities. For this reason, many speech language pathologists will recommend an AAC device (augmentative alternative communication) to ease that frustration. Often, parents are concerned that an AAC device will cause their child to never speak orally again. Being a mother of two children, I completely understand this worry. And, now I will put it to bed.
It has been well documented that children, and adults, do what is easier and faster when communicating. If speech is more efficient than using a device, oral communication will dominate (and vise versa). Often AAC is used as a “bridge,” helping patients access expressive language as soon as possible, while they develop the skills required to verbally express their wants, needs, thoughts, and ideas independently.
What can we do to help children with CAS increase their speech skills? Research by Murray, McCabem & Ballard (2013) noted 3 treatment approaches that had evidenced positive effects:
1.Dynamic Temporal and tactile Cueing (younger children, 3-6 years)
2.Rapid Syllable Transition (7-10 years)
3.Integrated Phonological Awareness Intervention
Research also states that intensity is key to treatment success. This means that the preferred therapy delivery model is 20-30 minutes, for 3-4 days per week. Now, if you are a busy parent/caregiver, like we all are, this sounds daunting. And, if you are a speech therapist with a packed caseload or have a lot of clients with finicky insurance providers, this sounds daunting as well. But, in my honest opinion, I think this service delivery model is possible if we employ parents as facilitators. That involves parents observing speech sessions, getting training from the speech therapist, and employing a home practice daily. By practicing motor speech skills 10-15 minutes every day during activities of daily living (i.e. bath time, getting ready for school, homework time, cooking dinner), the practice will inherently be both frequent and intense. And, outcomes will be better. For some children, speech is similar to learning an instrument in that daily practice is needed to foster the muscle memory required for performance of the task.
Potential Symptom that your child may have CAS:
-Lack of babbling as a baby
-Inconsistent errors on consonants and vowels
-Lengthened and disrupted transitions between sounds and syllables- difficulty moving from one articulatory context to the next.
-Slow rate of speech
-Groping
-Increased difficulty with multisyllabic words
-Inappropriate prosody (intonation)
-Inconsistent voicing errors
If your child is displaying any of these signs, a formal speech language evaluation is warranted.
Aimee Brigham, MCD, CCC-SLP is an independent contractor and contributor to Chew Chew Mama with over ten years of experience. See more of Aimee’s articles here. Do you need help? You can speak directly with Aimee Brigham about your child’s speech and language.
Book time for a coast-to-coast virtual consultation with Aimee here.
References:
1. Edeal, D. M., & Gildersleeve-Neumann, E. (2011). The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 20, 95-110.
2. Murray, E., McCabe, P., & Ballard, K.J. (2013). A systematic review of treatment outcomes for children with childhood apraxia of speech. American Journal of Speech-Language Pathology, 23, 286-504.
3. Namasivayam, A.K., Pukonen, M., Goshulak,D., Hard, J., Rudzicz, F., Rietveld, T., Maassen, B., Kroll, R., Lieshout, P. (2015). Treatment intensity and childhood apraxia of speech. Journal of Language and Communication Disorders, 0, 1-18.
4. Thomas, D. C., McCabe, P., & Ballard, K. J. (2014). Rapid syllable transitions (ReST) treatment for childhood apraxia of speech: the effect of lower dose-frequency. Journal of Communication Disorders, 51, 29-42.
5. Campbell, T. F. (2003). Childhood apraxia of speech: Clinical symptoms and speech characteristics. In L. D. Shriberg & T. F. Campbell (Eds.), Proceedings of the 2002 Childhood Apraxia of Speech Symposium, 37-40.
- Shriberg et al (1999). Prevalence of speech delay in 6-year-old children and comorbidity with language impairment. Journal of Speech Language Hearing Research, 42(6):1461-1481.
- Ryan is an alias to protect the client; some details have also been altered.
