Understanding Childhood Apraxia of Speech: Causes, Symptoms, and Treatment Options

Childhood Apraxia of Speech (CAS) is a motor speech disorder. While kids with CAS have a strong understanding of the words and sentences they want to say, CAS makes it challenging for children to speak clearly due to misfired brain signals. Usually, the brain coordinates what a person wants to say with the movements necessary to make speech sounds. This happens when the brain sends signals to speech muscles like the tongue, soft palate, and lips. With CAS, this coordination doesn't happen naturally. 

It's integral that parents and caregivers understand CAS if they suspect their child might have it. Identifying CAS early on means that parents and caregivers can seek help for their child as soon as possible. Early intervention matters for kids with CAS and can help them communicate effectively long-term. While there is no cure for CAS, there is treatment. So, what should you know about CAS and how to support your child?

First, let’s talk about factors that may contribute to CAS and symptoms to look out for. Then, we’ll discuss the diagnostic process, treatment options, and potential long-term outcomes for children with CAS.

Causes of Childhood Apraxia of Speech

CAS is sometimes also called verbal apraxia, developmental apraxia, developmental apraxia of speech, or developmental verbal dyspraxia. Verbal apraxia itself can be acquired (e.g., following brain injury) or developmental. If a child has developmental apraxia, it means that verbal apraxia was present from birth. Parents are not at fault for CAS and cannot cause it, though genetics and other factors can play a role. 

Neurological factors

Although CAS affects a small percentage of children, it can be more common in children with related concerns and conditions. For example, kids with Autism Spectrum Disorder (ASD) and epilepsy are more likely to have CAS. Many children with CAS have co-occurring conditions or concerns of some kind.

Genetic factors

About a third of CAS cases have a genetic cause. CAS can be linked to gene variations or alterations in genes. For example, changes in the FOXP2 gene have been linked to CAS and other speech disorders in research. If a child has CAS, it doesn't mean it was "passed down" directly from another family member. Instead, de novo variations (where a gene variation is seen within the family for the first time) appear to be more common in kids with CAS. Kids who have a family member with a communication disorder or learning disability, however, are also more likely to have CAS.

Environmental factors

Many parents are concerned that environmental factors may impact the development of CAS. At this time, there is no definitive evidence supporting environmental factors as a cause of developmental verbal apraxia. 

Symptoms of Childhood Apraxia of Speech

With CAS, speech development doesn’t follow typical patterns. CAS is not the same as a speech delay. Sometimes, CAS can be confused with another speech sound disorder, so learning the specific symptoms of CAS can be vital. Usually, kids with CAS can be diagnosed by the time they're about three years old. Here are some specific signs of the CAS you may notice as a parent.

Difficulty coordinating speech movements

Due to trouble coordinating speech movements, kids with CAS may find it physically difficult to say words. Some words or phrases are more challenging than others for kids with CAS. For example, your child may restart a word or phrase after their first attempt before getting the sound placement right.

Inconsistent speech sound errors

With CAS, a child's speech errors and skills might be inconsistent. For example, they may pronounce vowels correctly in some words but not others. Kids with CAS may also:

• Find it easier to say longer words vs. shorter words.
• Stress the wrong part of a word.
• Leave out parts of words.

If you notice that your child says words differently each time or struggles more with longer words, it could indicate CAS. 

Limited vowel and consonant combinations

Limited vowel and consonant combinations are a key sign of CAS that professionals will look for during the diagnostic process. For example, difficulty pronouncing vowels is more common in CAS than in other speech sound disorders.

Difficulty with prosody and rhythm of speech

"Prosody" in speech refers to the stress, rhythm, and annotation patterns a person uses when they speak. It’s what many people use to convey emotions and the purpose of their speech. For example, you might stress certain words or sounds to communicate sarcasm.

A child with CAS may:

• Emphasize the wrong part of a word.
• Make long pauses between sounds.
• Speak with an unusual rhythm.
• Use atypical annotation or pitch.

Since a child with CAS can display differences in prosody, it leaves them at risk of getting misunderstood during conversation. Prosody is one of the things that a speech-language pathologist might work on with a child for this reason.

Diagnosis of Childhood Apraxia of Speech

Diagnosing CAS involves ruling out other speech sound disorders and causes. In some cases, providers can diagnose young children by detecting the early signs of CAS. Alternatively, young children (under three years old) who show signs of CAS may require continued monitoring for a later diagnosis. Kids with co-occurring concerns may need specialized treatment in addiction to speech therapy.

Speech and language evaluation

Speech-language pathologists play an essential role in diagnosing CAS. As part of the diagnostic process, a speech pathologist will provide a comprehensive speech assessment. During the assessment, speech-language pathologists may ask a child to perform specific speech tasks, like repeating a certain word multiple times or repeating a list of words.

Physical examination

Physical examinations may rule out or detect possible structural concerns affecting a child's speech, such as a tongue tie, weakness of the speech muscles, or cleft palate. Reviewing a child's medical history alongside an oral mechanism exam and comprehensive speech and language evaluation is necessary.

Neurological testing

Kids may need to see a pediatric neurologist during the diagnostic process for CAS in some, but not all, cases. For example, neurological testing may be performed if a child shows signs of potential seizure activity, muscle imbalance, or tremors.

Treatment Options for Childhood Apraxia of Speech

Since CAS is a motor-based disorder, treatment focuses primarily on helping children make the correct movements to produce accurate speech sounds. CAS treatment involves working with a speech-language pathologist (SLP) for speech therapy. A child's speech therapy goals will be determined based on their current verbal language skills, like whether or not they currently speak in full sentences. 

It's essential that speech therapists focus not just on motor movements but on connecting specific motor movements to specific sounds. CAS is not caused by muscle weakness and is not treated by strengthening orofacial muscles. 

Speech therapy

Kids with CAS may receive speech therapy at school or in a speech-language pathologist's office at a speech therapy center. Speech-language pathologists working with CAS use a number of different strategies. While working with CAS, speech-language pathologists may:

• Focus on teaching a child important words, such as "help," "yes," or "no."
• Practicing specific speech sounds and corresponding muscle movements. For example, a speech pathologist may instruct the child to "make their lips into a circle" to make the "w" sound in a word like "wait."
• Using tools like picture boards and non-verbal gestures to support communication.
• Use play activities and games to promote speech sounds.
• Role play and imitation.
• Cues and prompts. 

SLPs can use different types of therapy, such as Dynamic Temporal and Tactile Cueing, Integrated Phonological Awareness, the Nuffield Dyspraxia Program (3rd Edition), and Rapid Syllable Transition Training (ReST). The frequency of therapy for speech problems like CAS may be determined based on multiple factors. Many kids with CAS see speech pathologists for speech therapy multiple times per week. 

Intensive therapy programs

Kids with CAS may engage in intensive therapy programs that meet 3-5 days per week to work on their speech. Intensive therapy programs for CAS may include individual therapy, group therapy, or a combination of both. Individual speech therapy provides one-on-one support and is often essential. Overall, the right approach to treatment or combination of treatments is unique to each individual child. 

Augmentative and alternative communication (AAC) devices

An AAC device is a voice output device that helps people with various conditions that affect speech and language communication. This includes kids with CAS who may have a hard time producing effective verbal communication, even with treatment. There are different types of AAC devices. These include:

• Tablets and other handheld devices.
• Laptops.
• Apps.

AAC devices can aid a child's speech and language skills by helping them get more familiar with words and pronunciation. The right AAC device for a child may vary based on factors such as eyesight and reading skills.

Parent education and support

Parent education on CAS matters. Speech progress is not always linear for kids with CAS. It's integral that kids feel accepted, understood, and loved for who they are. As a parent, you can help your child by:

• Being patient when they speak.
• Practicing verbal language skills (e.g., articulation) at home.
• Working closely with the child’s SLP to get education and guidance for at-home activities.
• Providing child-friendly ways to practice or absorb speech and language. For example, reading aloud and playing games like “I Spy” that use language.
• Advocating for helpful school accommodations as needed. Kids with CAS may qualify for an individualized education plan (IEP). 

SLPs can help parents learn about CAS and provide individualized advice after evaluating or working with their child. Apraxia Kids (apraxia-kids.org) is a valuable resource for parents who want to learn about CAS, advocate for their child, find a speech therapist, and more.

Prognosis for Children with Childhood Apraxia of Speech

The prognosis or outcome of treatment for kids with childhood apraxia of speech can vary based on multiple factors. For example, the severity of CAS or co-occurring concerns or disorders that may impact speech therapy outcomes. This is not an extensive list of what could impact CAS outcomes.

Long-term outlook for speech development in CAS

The long-term outlook for speech development in children with CAS can vary. Children are at risk of continuing speech sound errors in adolescence and adulthood. However, we do know that early intervention and treatment can be incredibly effective, and some kids do achieve typical speech patterns with treatment. Children should see improvements within about three months of speech therapy. 

When treatment doesn’t result in typical speech, it can still lead to significant improvements in verbal speech or general communication. If children display limited progress in speech therapy, exploring alternative treatments is recommended. For example, an AAC device might be beneficial in this case. 

Importance of early intervention

The American Speech-Language Hearing Association recommends early intervention for children who either have or may have CAS. In children suspected of having CAS who don't yet have a definitive diagnosis, speech therapy can aid the diagnostic process while helping the child with overall speech and language development.

Continued support and therapy for ongoing progress

CAS does not go away on its own and is not something children will grow out of. Intervention is necessary. Goals will change as a child progresses in treatment, and it is essential that they continue therapy as recommended. Kids with CAS often need fewer speech therapy sessions per week as time goes on (e.g., as severity moves from severe to moderate or moderate to mild). 

Conclusion

Childhood Apraxia of Speech, or CAS, is a motor speech disorder. Difficulties in speech production with CAS have nothing to do with how a child thinks or how hard they try to make speech sounds. Instead, the brain misfires and does not coordinate motor movements necessary for speech naturally the way it usually would. Early intervention leads to improved speech outcomes in those with CAS. 

Parents and caregivers who suspect CAS should seek a speech assessment for their child as soon as possible. The most recommended treatment for CAS is working with a speech-language pathologist for speech therapy. Children with a speech sound disorder like CAS require custom treatment plans that meet their needs and consider any factors that could impact their treatment, like co-occurring conditions.