Childhood Apraxia of Speech

Childhood apraxia of speech (CAS) is a speech disorder where your child's mouth cannot make the quick movements needed to speak, even after their brain tells their mouth what to do. There is usually no muscle weakness. If your child has CAS, it may be difficult for them to plan and complete the quick mouth movements needed to make sounds into syllables, words and sentences (motor planning). CAS is also sometimes called verbal apraxia, developmental apraxia of speech or verbal dyspraxia.

In most cases the cause of CAS is unknown. Here at Children’s Hospital of Philadelphia (CHOP), we are always working to find out more about why this condition occurs in some children. We know it is a rare disorder. It only affects about 3 to 5% of all preschoolers with diagnosed speech disorders. It is more common for children to have other developmental speech disorders. CAS is sometimes seen with other conditions like genetic, neurological or developmental disorders. But sometimes there are no other conditions present.

The American Speech-Language-Hearing Association lists three features as the most common you may notice if your child has CAS:

1. Your child says the same word differently each time they say it.
2. Your child has difficulty starting or transitioning between sounds or words, making their speech sound disconnected or “choppy”.
3. Your child finds the timing, rhythm and flow of speech challenging.

A child with CAS is often hard to understand. In addition to the three symptoms above, your child may:

• Produce vowel sound errors
• Have a slow rate of speech
• Have stress or voicing errors
• Have a tough time starting oral movements to say something
• Have multiple sound errors that do not follow the patterns expected in young children
• Use a limited variety of consonant and vowel sounds
• Have difficulty with longer words
• Use extra mouth movements when trying to make speech sounds
• Say a word or words with an additional sound
• Say a word once perfectly but not be able to say it again
• Say automatic words (like “hi” and “thank you”) more easily than less routine words
• Switch sounds in words or add sounds or syllables to words
• Have differences in the quality of the voice that come from sound vibrations in the throat, mouth and nose (resonance or nasality differences)
• Have a history of late development of first words and sounds

Here at CHOP, we have a dedicated team of licensed speech-language pathologists (SLP) who can diagnose whether your child has CAS. Your child may be referred to our SLPs for evaluation by their pediatrician, neurologist or developmental pediatrician. Our SLP will first do a speech and language evaluation.

During the speech and language evaluation, our SLP will review your child’s birth, medical and developmental histories. They will evaluate your child’s ability to:

• Understand and use language
• Communicate using speech, sign language and/or gestures
• Produce consonant and vowel sounds, syllables, words and phrases
• Speak with appropriate timing, rhythm and flow of speech
• Move parts of their mouth, including tongue, lips and jaw
• Play and interact with others

Our SLP will look for signs of CAS by asking your child to say certain sounds, words and phrases. It is harder to diagnose CAS in very young children and children with limited language skills. Our SLP may not be able to diagnose or rule out CAS on the first visit. They may recommend therapy, teach you language-building activities to do with your child at home, or ask you to come back in a few months to check your child’s progress.

Our SLP will create goals to support your child’s ability to be understood by others. The therapy approach will depend on your child’s specific needs. Goals may include learning how to say speech sounds, syllables, words and phrases.

If your child has a limited number of words in their vocabulary, therapy will start with improving their functional communication skills. This may include having your child practice with word approximations, picture communication systems, and speech-generating devices. To reduce frustration, some children with CAS may use one of these methods to express themselves while their speech develops. As your child’s speech improves, these systems may no longer be needed.

Speech-language therapy sessions will involve you, your child, their other caregiver(s) and our SLP. Sessions may be play-based or structured with tabletop activities. This will depend on your child’s needs and abilities. Sessions will also include your child's interests and your family's culture. This leads to better engagement, relevance, learning and fun.

At CHOP, our goal is to identify and treat CAS so your child can have the best communication outcomes.

How long will speech therapy last?

Children improve at different rates. In general, if your child has CAS, they may be in speech therapy longer than children with other speech disorders. The length of therapy depends on the severity of your child’s CAS (mild, moderate or severe), but intensive therapy may last several years.

Speech therapy may occur in your home, at your child’s school and/or with a private SLP. As your child’s speech gets clearer and their sentences become longer, therapy intensity may be gradually reduced. Children with milder forms of CAS and young children (younger than age two) may require therapy less often. If your child has no other language, cognitive or behavioral concerns, they will usually make faster progress. If you have concerns about your child’s language, cognitive or behavioral development, it is important to address those concerns as well.

What will my child do in speech therapy?

It is important for therapy to be motivating and rewarding. Activities may include games, play and drill-work, along with engaging in strategies like repetition, feedback, cues (visual, touch and/or verbal) and imitation.

Our SLP may focus on developing a core vocabulary or “power words” with your child, like their name, age, names of family members and pets, “help”, “open”, “yes”, “no” and “all done.” These words and phrases will improve your child’s overall communication and decrease their frustration. Gestures, sign language, picture boards and electronic devices may also be introduced to support your child’s verbal communication.

Will my child need to do oral motor exercises?

In general, your child must practice talking. All practice with mouth movements should relate to a specific sound or word that your child is practicing. For example, our SLP may ask your child to, “Round your lips” for the “w” sound in “want”, when asking for a toy. Rounding lips to blow bubbles or a whistle will not directly improve your child’s speech production skills.

What can I do for my child at home?

Your child’s SLP will teach you how to help your child practice and communicate at home. If your child has CAS, they will need to practice speech outside of the therapy room. We recommend practicing for a few minutes, a few times each day. This tends to be more effective than practicing once per week for a longer amount of time. Your practice activities at home should include things that your child can do easily and well. This makes home practice fun and successful and builds your child’s confidence when speaking.

Does a child with CAS often have needs other than speech therapy?

Children with CAS often have difficulties with language skills, as well. Your child may need help with learning to speak in sentences, using correct grammar and communicating during social interactions and play. As children with CAS get older, they may have additional learning difficulties (like reading skills). Some children with CAS may have gross motor or fine motor issues requiring occupational or physical therapy.