Let’s Talk About: Apraxia

Childhood Apraxia of Speech

Childhood Apraxia of Speech (CAS) is a motor speech disorder that affects a child’s ability to speak clearly.  It is considered a “rare” disorder by many speech therapists.  Only 1-2 out of 1,000 have this diagnosis, and it affects males more often than females.  I posted information about articulation here.

Children with Childhood Apraxia of Speech know what they want to say, but have difficulty making the sounds correctly.  Their brain has trouble getting the correct signal to the mouth.  Speech therapy can help the child improve their ability to speak.  I like the analogy of trying to put on your turn signal in the car, but the radio goes on instead.  So you try again, and then the gas flap pops open.  It makes me appreciate how frustrating it must be for a child with apraxia!  I understand why some children may just shut down.

 

Characteristics of CAS

Children with Childhood Apraxia of Speech often have some of these following characteristics.  It can be tricky to diagnosis when a child is younger than 3 years of age.  If your child has many of these characteristics, see your pediatrician and especially a speech/language pathologist.  The American Speech/Language Hearing Association lists the following characteristics of CAS:

  • Was quiet as a baby and late to start talking
  • Only a few different consonant sounds and distorted vowels
  • Problems putting sounds together- longer words are harder to say than single syllable words
  • Age-appropriate receptive language skills 
  • Difficulty imitating what others say
  • Does not always say a word the same way when asked to repeat
  • May silently grope with his mouth when trying to make sounds
  • Hard for others to understand, especially those outside the family
  • May sound monotone or choppy

Children may also have trouble with fine and/or gross motor skills.  The brain may have trouble getting the right signal to other parts of the body and not just the mouth.  They may have feeding issues since the mouth is involved.  A full developmental evaluation may be necessary for young children.

Causes CAS

Parents often want to know if they caused Childhood Apraxia of Speech.  It’s hard not to feel that way when your child is struggling.  It’s important to know there is NOTHING the parents did to cause this disorder.  Medical complications during pregnancy or childhood have not been shown to cause Childhood Apraxia of Speech.  According to the website Apraxia-Kids, there are 3 different causes of CAS.

  • Neurological Impairment: an illness, infection or injury that happened before or after birth
  • Complex Neurodevelopmental Disorders: CAS can occur secondary to an initial diagnosis such as Autism, Fragile X, or Galactosemia, etc.
  • Idiopathic Speech Disorder: The cause may be “unknown” showing no obvious neurological abnormalities.

Idiopathic speech disorder is most commonly given as the cause. Unless obvious, the cause is unknown.  I know parents hate when the cause it unknown.  So much of the brain is not understood, so it can be tricky to understand why the brain doesn’t do what it is suppose to do.

 

Evaluation of CAS

If you have concerns that your child may have Childhood Apraxia of Speech, see your child’s pediatrician and set up an evaluation with a speech/language pathologist.  It’s also helpful to have your child’s hearing checked to rule out a hearing loss causing speech issues.

The evaluation typically includes getting background information about your child.  The speech/language pathologist will do an oral motor examination by looking inside your child’s mouth and seeing how the lips and tongue are able to move.  Often times, children with CAS will have difficulty following directions like stick out your tongue, move it to the side, pucker your lips.  An articulation test and possibly a language test will be administered to get an accurate look at your child’s speech and language skills.

The Kaufman Speech Praxis Test for Children can be a helpful tool used by your speech/language pathologist during the evaluation.

 

Treatment of CAS

Research suggests that treatment sessions occur 3-5 times a week to help improve the speech of a child with CAS. This may be overwhelming and difficult to do. Many times, home therapy plans are provided to help if it is difficult to schedule therapy that often.  It is alway better to have short consistent practice than long inconsistent practice.

I often describe therapy as similar to playing the piano.  At first playing a song is difficult.  You need to look at the music and look at your hands.  The song may be slow and a bit jerky. You must play the piano daily at least 20-30 minutes.  It’s a lot of drill work to create muscle memory.

Eventually, you won’t need to look at your hands.  Your song will be faster and flow.  You might not even need to look at the music.

Treatment must be consistent, frequent, and have opportunities for multiple repetitions.  The child must be able to focus on the face of the therapist.  Children with attention difficulties will often have a harder time making progress.

Below are some typical treatment strategies that help children with apraxia of speech make progress with their speech productions.  Some strategies may not work for your child, so don’t be alarmed if your therapist is not using ALL of the below approaches.

PROMPT: Prompts for Restructuring Oral Muscular Phonetic Targets

This strategies uses tactile cues on the fact.  The therapist will touch the child’s face in different places to give the muscles of the face used in speech input while the child is talking.  I love this strategies for targeting vowels.  It really helps the child understand how to use their lips and jaw to make different sounds.  Some children may not like having their face touched.  This strategies may not be helpful for that child.

Cycles Approach

This approach works on a set of sounds for a short amount of time.  It moves on to a different sent for a short amount of time before it returns to the initial set.  This is a new treatment approach for me since I graduated.  I’ve been reading a lot about it since I first heard about it from a recent graduate.  Absolutely love being with new grads.  It helps to keep me up-to-date.  I know many parents worry when their therapist is considered “young” or “new,” but don’t forget that they have access to the new research that seasoned therapists may not.

Kaufman Speech Praxis Cards

These cards come in a set that focuses on Consonant/Vowel (CV) combinations.  It starts with simple combinations (CV) and increases in complexity (CVCVCV).  I like these cards a lot and use them daily with many of my clients who have CAS and who do not have CAS.  I like the size and visual appeal of the pictures.  Check it out here and here.

Dynamic Temporal and Tactile Cueing (DTTC)

This strategies focuses on helping the child appropriately shape the production and practicing those productions.  It’s another new strategy for me.  I’m currently learning about it from an online course taught by Dr. Edythe Strand.  It starts with imitation.  If that is difficult, then the child says the target word simultaneously with the therapist with slowed speech and elongated vowels.  The support from the therapist is faded as the child is given a chance to say the word independently with appropriate rate and prosody.

AAC

Augmentative Alternative Communication may be a necessary and helpful strategies if the child is severely unintelligibly.  This can be through pictures, signs, or a speech output device.  This can give the child a method of communicating while working on improving speech.  Parents may fear using AAC because they want the focus to be on “speech.”  Speech will alway be the end goal, but it’s important that the child have access to a mode of communication.  It decreases frustration and often helps give the child independence.

Prosody

Children with Childhood Apraxia of Speech often sound monotone or choppy.  An important component of therapy will target this area to help the child sound more appropriate.

 

The above strategies are used to help the child go from where they are (i.e., one syllable words) to the next step (i.e., two syllable words).  The end goal is age-appropriate speech sounds and fluent speech that is intelligible.  Children with CAS may be in speech therapy a long time with slow progress, but they do make progress.  They do graduate from speech therapy services!

What treatment strategies have worked for you?

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