What is Apraxia?

These are commonly heard statements from parents of children with childhood apraxia of speech (CAS). The most common description of a child with CAS is that he or she is often very difficult to understand.

CAS is a neurologically-based speech disorder in which there is a disruption in the motor planning for speech production, typically without muscle weakness. In other words, the child has difficulty programming and coordinating the complex oral movements to sequence sounds into syllables, syllables into words and words into phrases.

According to the American Speech- Language-Hearing Association (ASHA, 2007), the three most common features in children with apraxia of speech are:

1. Inconsistent errors on consonants and vowels in repeated productions of syllables or words (i.e., a child says the same word differently each time he tries to produce it)
2. Difficulty producing longer, more complex words and phrases
3. Inappropriate prosody and stress in word/phrase production (i.e., difficulty with the timing, rhythm and flow of speech)

Some additional features or characteristics of speech production associated with this diagnosis include:

• Late development of the child’s first words and sounds
• A decreased sound inventory (i.e., lack of the variety of consonant and vowel sounds expected at a certain age)
• Multiple and/or unusual sound errors
• Vowel sound errors
• Groping (i.e., excessive movements of the mouth, attempting to position the mouth for sound production)
• Persistent or frequent regression in the number of words produced
• Differences in performance of automatic speech (e.g., “hello” and “thank you”) versus voluntary speech (voluntary is often more affected)
• Errors in the order of sound production in words (i.e., sounds omitted, switched, or added to words and within words).

CAS is a rare condition experienced in less than 1 percent of all preschool children. Prevalence data on this disorder is limited. An accurate diagnosis requires a comprehensive speech and language evaluation by a speech-language pathologist (SLP) who will evaluate the child’s speech skills and expressive and receptive language abilities, while gathering information from the family regarding how the child communicates at home and in other situations.

It is important that the SLP evaluating the child has experience and expertise in diagnosing and working with CAS so that a differential diagnosis can be made and other possible diagnoses are ruled out. For example, CAS is often confused with a severe articulation disorder, since both diagnoses include poor speech intelligibility. Unfortunately, the approach taken to address an articulation disorder is vastly different than the approach for CAS, and confusing the two could result in reduced therapy gains.

An assessment for CAS must include an evaluation of the child’s expressive and receptive language abilities, as many children with CAS demonstrate deficits in their language skills. In addition, gaps between receptive and expressive language skills, word order confusions, and difficulty with word recall are common in CAS. It is through a thorough assessment of each child’s abilities that therapy goals can be developed based on his individual needs.

Treatment for apraxia should be intensive and may last several years depending on the severity of the disorder. Many children with CAS benefit from:

• Multiple repetitions and repeated practice of sound sequences, words and phrases in therapy
• The use of visual prompting to show how speech sounds are made as sequences of sounds are combined into words
• Co-production, or having the child say the word at the same time as the SLP or caregiver

If the child has a limited number of words in his vocabulary, therapy will initially focus on improvement of functional communication skills. It is critical for the child to experience the power of communication through positive interactions. If producing words is too difficult for the child initially, positive interactions may be achieved through other modes of communication (e.g., sign language, picture communication boards, voice output communication devices). Using other modes of communication while working on speech production has been found to promote verbal skills and decrease frustration while communicating.

It is important for SLPs, teachers, parents, related professionals and all family members to be actively involved in the treatment process so that maximum progress is achieved. Additional research on CAS is needed to explore causal factors, diagnostic criteria and the efficacy of various therapy approaches. But with commitment from professionals, researchers and families, significant progress and improvements can be made for children with CAS.

References

Childhood Apraxia of Speech [Position Statement]. American Speech-Language-Hearing Association. (2007). www.asha.org/policy.

Childhood Apraxia of Speech [Technical Report]. American Speech-Language-Hearing Association. (2007). www.asha.org/policy.

The Childhood Apraxia of Speech Association of North America (CASANA). (2013) Apraxia-KIDS Library. www.apraxia-kids.org.

Childhood Apraxia of Speech: Assessment/Treatment for the School-Aged Child. Shelley L. Velleman, Ph.D., CCC-SLP, ASHA Convention Presentation Report. 2006.